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Elements of Liability


On July 28, 1994, respondent 3 months pregnant Editha Ramolete was brought to Lorma Medical Center
(LMC) in San Fernando, La Union due to vaginal bleeding upon advise of petitioner related via telephone,
Editha was admitted to the LMC on the same day. A pelvic sonogram was then conducted on Editha
revealing the fetus weak cardiac pulsation. The following day, Editha repeat pelvic sonogram showed that
aside from the fetus weak cardiac pulsation, no fetal movement was also appreciated. Due to persistent
and profuse vaginal bleeding, petitioner advised her to undergo a D&C procedure. She was discharged the
following day. On September 16, 1994, Editha was once gain brought at the LMC, as she was suffering
from vomiting ans severe abdominal pains. Editha was attended by Drs. Dela Cruz, Mayo and Komiya. Dr.
Mayo allegedly informed Editha that there was a dead fetus in the latter’s womb, after Editha went
laparectomy, she was found to have massive intra abdominal hemorrhage and ruptured uterus. Thus, she
had to go hysterectomy and as a result no more chance to bear a child.

Issue: Whether or not petitioner is liable for medical malpractice.

Held: No. Medical malpractice is a particular form of negligence which consists in the failure of a physician
or surgeon to apply to his practice of medicine that degree of care and skill which is ordinarily employed
by the profession generally under similar conditions, and in like surrounding circumstances. In order to
successfully pursue such a claim, a patient must prove that the physician or surgeon either failed to do
something which a reasonably prudent physician or surgeon would not have done, and that the failure or
action caused injury to the patient.

There are four elements involved in medical negligence cases: duty, breach, injury, and proximate cause..

A physician-patient relationship was created when Editha employed the services of the petitioner. As
Editha’s physician, petitioner was duty-bound to use at least the same level of care that any reasonably
competent doctor would use to treat a condition under the same circumstances. The breach of these
professional duties of skill and care, or their improper performance by a physician surgeon, whereby the
patient’s injured in body or in health, constitutes actionable malpractice, as to this aspect of medical
malpractice, the determination of the reasonable level of care and the breach thereof, expert testimony
is essential. Further, in as much as the causes of the injuries involved in malpractice actions are
determinable only in the light of scientific knowledge, it has been recognized that expert testimony is
usually necessary to suspect the conclusion as to causation.

It is undisputed that Editha did not return for follow-up evaluation, in defiance of the petitioner’s advice.
This is as found out is the proximate cause of the injury she sustained.
Ramos vs CA

Res Ipsa Loquitur


Erlinda Ramos underwent a surgical procedure to remove stone from her gall bladder (cholecystectomy).
They hired Dr. Hosaka, a surgeon, to conduct the surgery at the De Los Santos Medical Center (DLSMC).
Hosaka assured them that he would find a good anesthesiologist. But the operation did not go as planned,
Dr. Hosaka arrived 3 hours late for the operation, Dra. Gutierrez, the anesthesiologist “botched” the
administration of the anesthesia causing Erlinda to go into a coma and suffer brain damage. The botched
operation was witnessed by Herminda Cruz, sister in law of Erlinda and Dean of College of Nursing of
Capitol Medical Center. The family of Ramos (petitioners) sued the hospital, the surgeon and the
anesthesiologist for damages. The petitioners showed expert testimony showing that Erlinda's condition
was caused by the anesthesiologist in not exercising reasonable care in “intubating” Erlinda. Eyewitnesses
heard the anesthesiologist saying “Ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki
ang tiyan.”

Diagnostic tests prior to surgery showed that Erlinda was robust and fit to undergo surgery.

The RTC held that the anesthesiologist ommitted to exercise due care in intubating the patient, the
surgeon was remiss in his obligation to provide a “good anesthesiologist” and for arriving 3 hours late and
the hospital is liable for the negligence of the doctors and for not cancelling the operation after the
surgeon failed to arrive on time. The surgeon, anesthesiologist and the DLSMC were all held jointly and
severally liable for damages to petitioners. The CA reversed the decision of the Trial Court.

ISSUES: Whether or not the private respondents were negligent and thereby caused the comatose
condition of Ramos.


Yes, private respondents were all negligent and are solidarily liable for the damages.


Res ipsa loquitur – a procedural or evidentiary rule which means “the thing or the transaction speaks for
itself.” It is a maxim for the rule that the fact of the occurrence of an injury, taken with the surrounding
circumstances, may permit an inference or raise a presumption of negligence, or make out a plaintiff’s
prima facie case, and present a question of fact for defendant to meet with an explanation, where
ordinarily in a medical malpractice case, the complaining party must present expert testimony to prove
that the attending physician was negligent.
This doctrine finds application in this case. On the day of the operation, Erlinda Ramos already
surrendered her person to the private respondents who had complete and exclusive control over her.
Apart from the gallstone problem, she was neurologically sound and fit. Then, after the procedure, she
was comatose and brain damaged—res ipsa loquitur!—the thing speaks for itself!

Negligence – Private respondents were not able to disprove the presumption of negligence on their part
in the care of Erlinda and their negligence was the proximate cause of her condition. One need not be an
anesthesiologist in order to tell whether or not the intubation was a success. [res ipsa loquitur applies
here]. The Supreme Court also found that the anesthesiologist only saw Erlinda for the first time on the
day of the operation which indicates unfamiliarity with the patient and which is an act of negligence and

The head surgeon, Dr. Hosaka was also negligent. He failed to exercise the proper authority as the “captain
of the ship” in determining if the anesthesiologist observed the proper protocols. Also, because he was
late, he did not have time to confer with the anesthesiologist regarding the anesthesia delivery.

The hospital failed to adduce evidence showing that it exercised the diligence of a good father of the
family in hiring and supervision of its doctors (Art. 2180). The hospital was negligent since they are the
one in control of the hiring and firing of their “consultants”. While these consultants are not employees,
hospitals still exert significant controls on the selection and termination of doctors who work there which
is one of the hallmarks of an employer-employee reationship. Thus, the hospital was allocated a share in
the liability.

Damages – temperate damages can and should be awarded on top of actual or compensatory damages
in instances where the injury is chronic and continuing.
Cantre vs Spouses Go

Captain of the Ship doctrine


Petitioner Dr. Milagros L. Cantre is a specialist in obstetrics and gynecology at the Dr. Jesus Delgado
memorial Hospital. She was the attending physician of respondent Nora Go, who was admitted at the said
hospital on April 19, 1992. At 1:30am of April 20, 1992, Nora gave birth to her fourth child, a baby boy.
However, at around 3:30am Nora suffered profuse bleeding insider her womb due to some parts of the
placenta were not completely expelled from her womb after delivery consequently, Nora suffered
hypovolemic shock, resulting in a drop in her blood pressure to 40/0. Petitioner said the assisting resident
physician performed various medical procedures to stop the bleeding and to restore Nora’s blood
pressure. Her blood pressure was frequently monitored with the use of a sphygmamometer. While
petitioner was massaging Nora’s uterus for it to contract and stop bleeding, she ordered a drop light to
warm Nora and her baby. Nora remained unconscious until she recovered. While in the recovery room,
her husband, respondent John David Z. Go noticed a fresh gasping wound 2 1/2″ x 3 1/2″ in the inner
portion of her left arm, close to the armpit. He asked the nurses what caused the injury. He was informed,
it was a burn. An investigation was filed by Nora’s husband and found out from the petitioner that it was
caused by the blood pressure cuff, however, this was contrary to the findings from a medico-legal report
which stated that it was indeed a burn and that a drop light when placed near a skin for about 10mins
could cause such burn. Nora was referred to a plastic surgeon from the hospital and skin grafting was
done on her and scar revision but both still left a mark on Nora’s arm compelling the respondent spouse
to file a complaint for damages against petitioner.

Issue: Whether or not petitioner is liable for the injury referred by Nora.

Held: Yes. The Hippocratic oath mandates physicians to give primordial consideration to the well-being of
their patients. If a doctor fails to live up to his precept, he is accountable for his acts. This is
notwithstanding, courts face a unique restraint in adjudicating medical negligence cases because
physicians are not guardians of care and they never set out to intentionally cause injury to their patients.
However, intent is immaterial in negligence cases because where negligence exist and is proven, it
automatically gives the injured a right to reparation for the damage caused.

In cases, involving medical negligence, the doctrine of res ipsa liquitor allows the mere existence of an
injury to justify a presumption of negligence on the part of the person who controls the instrument causing
the injury, provided that the following requisites concur:

The accident is of a kind which ordinarily does not occur in the absence of someone’s negligence;
It is caused by an instrumentality within the exclusive control of the defendant or defendants;

The possibility of contributing conduct which would make the plaintiff responsible is eliminated.

All of these three requisites were present in the case at bar.

Under the the captain of the ship doctrine, the surgeon in charge of the operation is liable for the
negligence of his assistants during the time when those are under the surgeons control.

Chan, Jr. vs. INC

Joint Tortfeasors


The Aringay Shell Gasoline Station is owned by the petitioner. It is located in Sta. Rita East, Aringay, La
Union, and bounded on the south by a chapel of the respondent. The gasoline station supposedly needed
additional sewerage and septic tanks for its washrooms. In view of this, the services of Dioscoro Ely Yoro
(Yoro), a retired general of the Armed Forces of the Philippines, was procured by petitioner, as the former
was allegedly a construction contractor in the locality. Diggings thereafter commenced. After some time,
petitioner was informed by the members of the respondent that the digging traversed and penetrated a
portion of the land belonging to the latter. The foundation of the chapel was affected as a tunnel was dug
directly under it to the damage and prejudice of the respondent. After four years of hearing the case, the
trial court promulgated its decision holding that the diggings were not intended for the construction of
sewerage and septic tanks but were made to construct tunnels to find hidden treasure. The trial court
adjudged the petitioner and Yoro solidarily liable to the respondent on a 35%-65% basis (the petitioner
liable for the 35%)

RTC ruled in favor of INC; CA affirmed.

Issue: Whether Chan and Yoro are joint tortfeasors.


For the damage caused to respondent, petitioner and Yoro are jointly liable as they are joint tortfeasors.
Verily, the responsibility of two or more persons who are liable for a quasi-delict is solidary. As a general
rule, joint tortfeasors are all the persons who command, instigate, promote, encourage, advise,
countenance, cooperate in, aid or abet the commission of a tort, or who approve of it after it is done, if
done for their benefit. ndubitably, petitioner and Yoro cooperated in committing the tort. They even had
provisions in their MOA as to how they would divide the treasure if any is found within or outside
petitioners property line. Thus, the MOA, instead of exculpating petitioner from liability, is the very noose
that insures that he be so declared as liable.

Casumpang vs Cortejo

Elements of Liability; Standard of Care


On April 22, 1988, at about 11:30 in the morning, Mrs. Jesusa Cortejo brought her 11-year old son, Edmer
Cortejo (Edmer), to the Emergency Room of the San Juan de Dios Hospital (SJDH) because of difficulty in
breathing, chest pain, stomach pain, and fever. Dr. Ramoncito Livelo (Dr. Livelo) initially attended to and
examined Edmer. After taking Edmer's medical history, Dr. Livelo took his vital signs, body temperature,
and blood pressure.6 Based on these initial examinations and the chest x-ray test that followed, Dr. Livelo
diagnosed Edmer with "bronchopneumonia. Mrs. Cortejo did not know any doctor at SJDH. She was
thereafter assigned to Dr. Noel Casumpang (Dr. Casumpang), a pediatrician also accredited with Fortune
Care. Mrs. Cortejo recalled entertaining doubts on the doctor's diagnosis. Dr. Casumpang next visited and
examined Edmer at 9:00 in the morning the following day. Still suspicious about his son's illness, Mrs.
Cortejo again called Dr. Casumpang's attention and stated that Edmer had a fever, throat irritation, as
well as chest and stomach pain. Mrs. Cortejo also alerted Dr. Casumpang about the traces of blood in
Edmer's sputum. Despite these pieces of information, however, Dr. Casumpang simply nodded, inquired
if Edmer has an asthma, and reassured Mrs. Cortejo that Edmer's illness is bronchopneumonia. Edmer
vomited "phlegm with blood streak" prompting the respondent (Edmer's father) to request for a doctor
at the nurses' station. Forty-five minutes later, Dr. Ruby Sanga-Miranda (Dr. Miranda), one of the resident
physicians of SJDH, arrived. She claimed that although aware that Edmer had vomited "phlegm with blood
streak," she failed to examine the blood specimen because the respondent washed it away. She then
advised the respondent to preserve the specimen for examination. Dr. Miranda then examined Edmer's
"sputum with blood" and noted that he was bleeding. Suspecting that he could be afflicted with dengue,
she inserted a plastic tube in his nose, drained the liquid from his stomach with ice cold normal saline
solution, and gave an instruction not to pull out the tube, or give the patient any oral medication. Dr.
Miranda advised Edmer's parents that the blood test results showed that Edmer was suffering from
"Dengue Hemorrhagic Fever." Edmer was transferred to Makati Medical Center, but it was too late. Edmer
died at 4:00 in the morning of April 24, 1988.24 His Death Certificate indicated the cause of death as
"Hypovolemic Shock/hemorrhagic shock;" "Dengue Hemorrhagic Fever Stage IV."

Whether or not the petitioning doctors had committed "inexcusable lack of precaution" in diagnosing and
in treating the patient


Yes. The elements of medical negligence are: (1) duty; (2) breach; (3) injury; and (4) proximate causation.

Duty refers to the standard of behavior that imposes restrictions on one's conduct. It requires proof of
professional relationship between the physician and the patient. Without the professional relationship, a
physician owes no duty to the patient, and cannot therefore incur any liability.

Breach of duty occurs when the doctor fails to comply with, or improperly performs his duties under
professional standards. This determination is both factual and legal, and is specific to each individual case.

If the patient, as a result of the breach of duty, is injured in body or in health, actionable malpractice is
committed, entitling the patient to damages.

To successfully claim damages, the patient must lastly prove the causal relation between the negligence
and the injury. This connection must be direct, natural, and should be unbroken by any intervening
efficient causes. In other words, the negligence must be the proximate cause of the injury.44 The injury
or damage is proximately caused by the physician's negligence when it appears, based on the evidence
and the expert testimony, that the negligence played an integral part in causing the injury or damage, and
that the injury or damage was either a direct result, or a reasonably probable consequence of the
physician's negligence.

Standard of Care and Breach of Duty

A determination of whether or not the petitioning doctors met the required standard of care involves a
question of mixed fact and law; it is factual as medical negligence cases are highly technical in nature,
requiring the presentation of expert witnesses to provide guidance to the court on matters clearly falling
within the domain of medical science, and legal, insofar as the Court, after evaluating the expert
testimonies, and guided by medical literature, learned treatises, and its fund of common knowledge,
ultimately determines whether breach of duty took place.

Whether or not Dr. Casumpang and Dr. Miranda committed a breach of duty is to be measured by the
yardstick of professional standards observed by the other members of the medical profession in good
standing under similar circumstances. It is in this aspect of medical malpractice that expert testimony is
essential to establish not only the professional standards observed in the medical community, but also
that the physician's conduct in the treatment of care falls below such standard.
Lucas vs Tuano

Standard of Care; Burden of Proof


Sometime in 1988, petitioner Peter Paul Patrick Lucas contracted "sore eyes" in his right eye. Upon
consultation with Dr. Tuano, Peter narrated that it has been 9 days since the problem with his right eye
began, and that he was already taking Maxitrol to address the eye problem. According to Dr. Tuano, he
performed "ocular routine examination" on Peter's eyes, wherein: 1. a cross examination Peter's eyes and
their surrounding area was made, and 2. Peter's visual acuity were taken, 3. Peter's eyes were palpated
to check the intraocular pressure of each; 4. the mortility of Peter's eyes were observed, and 5. the
ophthalmoscopy on Peter's eyes was used. On that particular consultation, Dr. Tuano diagnosed that Peter
was suffering from conjunctivitis or sore eyes. He then prescribed Spersacet C-eye drops for Peter and
told the latter to return for follow-up after one week. As instructed, Peter returned and Dr. Tuano
discovered that the right eye developed Epidemic Kerato Conjunctivitis, EKC, a viral infection. To address
the problem, Dr. Tuano prescribed Maxitrol, for a dosage of 6 times a day. However, the EKC was getting
worse yet Dr. Tuano still continued on advising the use of Maxittrol, despite Peter's discovery of the
inscribed warning written in its label. Upon examination, Dr. Tuano noted the hardness in Peter's right
eye and discovered that the tension in Peter's right eye was 39.0 Hg. Since the tension was way over the
normal IOP which only ranged from 10.0 Hg to 21.0 Hg, Dr. Tuano then ordered him to immediately
discontinue the use of Maxitrol and prescribed to the latter Diamox and Normoglaucon instead. He also
required Peter to go for a daily check-up in order for the former to closely monitor the pressure of the
latter' eyes. During one of Peter's regular follow-ups, Dr. Tuano noted the recurrence of EKC in Peter's
right eye. Thus, he referred Peter to Dr. Manuel Agulto, M.D., another opthalmologist specializing in
glaucoma treatment. Eventually, Peter, in claiming to have "steroid-induced glaucoma" and blaming Dr.
Tuano for the same, filed a civil complaint for damages against Dr. Tuano. In their complaint, petitioners
averred that as the direct consequence of Peter's prolonged use of Maxitrol, he suffered from steroid-
induced glaucoma which caused the elevation of his intra-ocular pressure, which caused the impairment
of his vision which may lead to total blindness. In rebutting petitioner's claim, Dr. Tuano asserted that the
treatment made by him more than three years ago has no causal connection to Peter's glaucoma. He
further explained that 'drug-induced glaucoma is temporary and curable, steroids have the side effect of
increasing intraocular pressure. Steroids are prescribed to treat Epidemic Kerato Conjunctivitis or EKC
which is an infiltration of the cornea as a result of conjunctivitis or sore eyes'. Hence, the steroid treatment
of Peter's EKC caused the steroid-induced glaucoma.

RTC Ruling

The RTC dismissed the Civil Case for insufficiency of evidence, opining that petitioners failed to prove by
preponderance of evidence that Dr. Tuano was negligent in his treatment of Peter's condition. The trial
court reasoned hat the recognized standards of the medical community has not been established in thiss
case, much less has causation been established to render Dr. Tuano liable. Further, absence of any medical
evidence to the contrary, the RTC ruled that it cannot accept petitioner's claim that the use of steroid is
the proximate cause of the damage sustained by Peter's eye.

Court of Appeals Ruling

The CA faulted petitioners because they failed to present any medical expert to testify that Dr. Tuano's
prescription of Maxitrol and Blephamide for the treatment of EKC on petiitioner's right eye was not proper
and that his palpation of Peter's right eye was not enough to detect adverse reaction to steroid.

During the trial in CA, Peter testified that Dr. Manuel Agulto told him that he should not have used steroid
for the treatment of EKC or that he should have used it only for two weeks, as EKC iss only a viral infection
which will cure in tself. However, Dr. Agulto was not presented by petitioners as a witness to confirm what
he allegedly told Peter and therefore, the latter's testimony is hearsay. Under Rule 130, Section 36 of the
Rules of Court, a witness can testify only to those facts which he knows of and his own personal
knowledge. Familiar and fundamental is the rule that hearsay testimony is inadmissible as evidence.

Petitioner's Motion for Reconsideration was denied by resolution, hence, this appeal.

Issue: Did the petitioners failed to prove by preponderance of evidence their claim for damages against
Dr. Tuano?

Court Ruling:

Only questions of law may be raised under Rule 45 of the Rules of Court as this court is not a trier of facts.

The said issue constitutes a question of fact, as the Supreme Court is asked to revisit anew the factual
findings of the RTC and the CA. While this general rule admits of certain exceptions, such as the
circumstance when the finding of fact of the Court of Appeals is premised on the supposed absence of
evidence, but is contradicted by the evidence on record.

The fact of want of competence or diligence is evidentiary in nature, the veracity of which can best be
passed upon after a full-blown trial for it is virtually impossible to ascertain the merits of a medical
negligence case without extensive investigation, research, evaluation and consultation with the medical

Petitioner's position in sum is that Peter's glaucoma is the direct result of Dr. Tuano's negligence in his
improper administration of the drug Maxitrol. Clearly, the present controversy is a classic illustration of a
medical negligence case against a physician based on the latter's professional negligence. In this type of
suit, the patient or his heirs, in order to prevail, is required to prove by is required to prove by
preponderance of evidence that the physician failed to exercise that degree of skill, care and learning
possessed by other persons in the same profession; and that as a proximate result of such faiure, the
patient or his heirs suffered damages.

For lack of a specific law geared towards the type of negligence committed by members of the medical
profession, such claim for damages is almost always anchored on the alleged violation of Article 2176 of
the Civil Code which states that "whoever by act or omission, causes damage to another, there being no
fault or negligence, is obliged to pay for the damage done. Such fault or negligence, is there is no pre-
existing contractual relation between the parties is called quasi-delict.

In medical negligence cases, the four essential elements are the following: 1. duty 2. breach 3. injury 4.
proximate cause, which must be established by the plaintiffs.

In order that there may be a recovery for an injury, it must be shown that the injury for which the recovery
is sought must be the legitimate consequence of the wrong done, the connection between the negligence
and the injury must be a direct and natural sequence of events, unbroken by intervening efficient causes.

Proximate cause: It is the cause, which is the natural and continuous sequence, unbroken by any efficient
intervening cause, produces the injury, and without which the result would not have occurred. That is,
the negligence must be the proximate cause of the injury.

Just as with the elements of duty and breach of the same, in order to establish the proximate cause by
preponderance of evidence, the patient must similarly use expert testimony, because the question of
whether the alleged professional negligence caused the patient's injury is generally one for specialized
expert knowledge beyond the ken of the average layperson; using the specialized knowledge and training
of his field, the expert's role is to present to the court a realistic assessment of the likelihood that the
physician's alleged negligence caused the patient's injury.

In this case, Dr. Tuano was able to clearly explain what is only required of ophthalmologists, in cases such
as Peter's is the conduct of standard tests/ procedures known as "ocular routine examination" composed
of five (5) test procedures, specifically: gross examination of the eyes and the surrounding area, taking of
the visual acuity of the patient, checking the intraocular pressure of the patient, checking the motility of
the eyes--and he did all those tests every time Peter went to see him for follow-up consultation and/or
Even if we are to assume that Dr. Tuano committed negligent acts in his treatment of Peter's condition,
the causal connection between Dr. Tuano's supposed negligence and Peter's injury still needed to be
established. The critical and clinching factor in a medical negligence case is proof of the causal connection
between the negligence which the evidence established and the plaintiff's injuries.

Civil procedure, burden of proof: In civil cases, the party having the burden of proof must establish his
case by a preponderance of evidence, or evidence which is more convincing to the court as worthy of
belief than that which is offered in opposition thereto. The party having the burden of proof must establish
his case by a preponderance of evidence or "evidence which is of greater weight or more convincing that
that which is offered in opposition to it; in the last analysis, it means the probability of truth.

It seems basic that what constitutes proper medical treatment is a medical question that should have
been presented to experts. If no standard is established through expert medical witnesses, then courts
have no standard by which to gauge the basic issue of breach by the physician or surgeon. The RTC, Court
of Appeals and even the Supreme Court; could not be expected to determine on its own what medical
technique should have been utilized for a certain disease or injury. Absent expert medical opinion, the
courts would be dangerously engaging in speculations.

Cruz vs CA

Elements of Liability; Standard of Care;

Burden of Proof

Facts: On March 22, 1991, prosecution witness, Rowena Umali de Ocampo, accompanied her mother to
the Perpetual Help Clinic and General Hospital situated in 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 examined by the petitioner who found a “Myoma” in her uterus, and scheduled her for a
hysterectomy operation on March 23, 1991. Rowena and her mother slept in the clinic on the evening of
March 22, 1991 as the latter was to be operated on the next day at 1pm. According to Rowena, she noticed
that the clinic was untidy and the windows and the floor were very dusty prompting her to ask the
attendant fora rag to wipe the window and floor with. Prior to the operation, Rowena tried to convince
her mother to not proceed with the operation and even asked petitioner for it to be postponed, however
it still pushed through after the petitioner told Lydia that operation must be done as scheduled. During
the operation, the assisting doctor of the petitioner, Dr. Ercillo went out of the operating room and asked
that tagmet ampules be bought which was followed by another instruction to buy a bag of blood. After
the operation, when Lydia came out of the OR, another bag of blood was requested to be bought,
however, the same was not bought due to unavailability of type A from the blood bank. Thereafter a
person arrived to donate blood which was later transferred to Lydia. Rowena then noticed her mother,
who was attached to an oxygen tank, gasping for breathe apparently, the oxygen tank is empty, so her
husband and petitioner’s driver bought an oxygen. Later, without the knowledge of Lydia’s relatives, she
was decided by the doctors to be transferred to San Pablo District Hospital were she was supposed to be
re-operated. After Lydia experienced shocks, she died.

Issue: Whether or not petitioner has been negligent which caused the death of Lydia Umali.

Held: Yes. Whether or not a physician has committed an “inexcusable lack of precaution” in the treatment
of his patient to be determined according to the standard of care observed by other members of the
profession in good standing under similar circumstances bearing in mind the advanced state of the
profession at the time of treatment or the present state of medical science. A doctor in effect represents
that, having the needed training and skill possessed by physicians and surgeons practicing in the same
field, he will employ such training, care and skill in the treatment of his patients. He therefore has a duty
to use at least the same level of care that any other reasonably competent doctor would use to treat a
condition under the same circumstances. It is in this aspect of medical malpractice that expert testimony
is essential to establish not only the standard of care of the profession but also that the physician’s
conduct in the treatment and care falls below such standard. Further, in as much as the causes of the
injuries involved in malpractice actions are determinable only in the light of scientific knowledge, it has
been recognized that expert testimony is usually necessary to the conclusion as to causation.

In litigations involving medical negligence, the plaintiff has the burden of establishing appellant’s
negligence and for a reasonable conclusion of negligence, there must be proof of breach of duty on the
part of the surgeon as well as causal connection of such breach and the resulting death of his patient.

In order that there may be recovery for an injury, however, it must be shown that the injury for which
recovery is sought must be legitimate consequence of the wrong done; the connection between the
negligence and the injury must be a direct and natural reference of events, unbroken by intervening
efficient causes. In other words, the negligence must be the proximate cause of the injury. For negligence,
no matter what it consists, cannot create a right of action unless it is the proximate cause of the injury
complained of and the proximate cause of an injury is that cause, which in natural and continuous
sequence, unbroken by any efficient intervening cause, produces the injury and without which the result
would have occurred.
The elements of reckless imprudence are:

That the offender does or fails to do an act;

That the doing or the failure to do that act is voluntary;

That it be without malice;

That material damage results from the reckless imprudence; and

That there is inexcusable lack of precaution on the part of the offender, taking into consideration his
employment or occupation, degree of intelligence, physical condition, and other circumstances regarding
persons, time, and place.

The possible causes of hemorrhage during an operation are:

1.) the failure of the surgeon to tie or suture a cut blood vessel;

2.) allowing a cut blood vessel to get out of control;

3.) the subsequent loosening of the tie or suture applied to a cut blood vessel; and

4.)and a clotting defect known as DIC.