LEGAL MEDICINE
The Filipino Physician
Discuss the journey a person must thread to become a
physician.
- A person must have a college degree, with the requisite
subject units.
- He must have passed the National Medical Admissions
Test (NMAT) to qualify to be admitted into a medical
school. Under NMAT rules, “[a] student shall be
allowed only three (3) chances to take the NMAT. After
three (3) successive failures, a student shall not be
allowed to take the NMAT for the fourth time.” In DECS
vs San Diego, the Supreme Court upheld the validity of
the three-flunk rule, saying that: “the medical
profession directly affects the very lives of the people,
unlike other careers which, for this reason, do not
require more vigilant regulation.”
- The Doctor of Medicine (M.D.) degree is a five year
graduate program intended to teach students the
essentials of being a Medical Doctor. The program
consists of three years of academic instruction, one
year of clinical clerkship and one year of post-graduate
internship.
- After passing the board exam, one can now be
considered a licensed doctor. But from there, he is
considered a general practitioner. He may also take
specializations and sub specializations.
RA No. 2382 or the Medical Act of 1959; PMA Code of Ethics
What are the objectives of the Medical Act?
- It provides for and shall govern the following:
1. Standardization and regulation of Medical
Education;
2. Examination for registration of physicians;
3. Supervision, control and regulation of the
practice of medicine in the Philippines
What are the two agencies created by virtue of the
Medical Act?
1. Board of Medical Education (Duties are now assumed
by the Commission on Higher Education)
2. Board of Medical Examiners (Duties are now assumed
by the Board of Medicine under PRC)
Who comprise the Board of Medical Education?
1. Secretary of Education or duly authorized
representative;
2. Secretary of Health or duly authorized representative;
3. Director of Bureau of Private schools or his duly
authorized representative;
4. Chairman of the Board of Medicine or his duly
authorized representative;
5. Dean of UP Med;
6. Council of Dean of Med Schools;
7. Representative chosen by PACU
What are the functions of the Board of Medical
Education?
1. Prescribes the minimum requisites for admission to a
medical school;
2. Prescribes the minimum physical facilities required of a
medical school;
3. Prescribes the minimum number and minimum
qualification of teaching personnel;
4. Prescribes the minimum required curriculum;
5. To authorize the implementation of experimental
medical curriculum in a medical school that has
exceptional faculty and instrumental facilities;
6. To accept applications for certification for admission to
a medical school and to keep a register of medical
students;
7. To select training hospitals; and
8. To promulgate rules necessary for the enforcement of
the above mentioned functions;
What are the requirements for admission into medical
school?
1. Must not have been convicted of a crime involving
moral turpitude;
2. Must be able to present the following:
a. Bachelor’s degree;
b. Certification of eligibility for entrance to a med
school from the Board of Medical Education;
c. Certification of GMC from at least two
professors; and
d. Birth certificate
What are the prerequisites for the practice of medicine?
1. At least 21 years of age;
2. Must have passed the medical board exams; and
3. Must be a holder of a valid, certificate of registration
issued by the Board of Medicine
Q: Once a person has passed the medical board exams,
is the issuance of the certificate of registration
ministerial on the part of the Board of Medicine?
- No. Section 8 of the Medical Act provides that “No
person shall engage in the practice of medicine in the
Philippines unless he is at least twenty-one years of
age, has satisfactorily passed the corresponding Board
Examination…” The operative word is “satisfactorily.”
Hence, if the Board is not satisfied with the
circumstances surrounding the examinee’s passing, it
has the discretion of postponing or refusing to issue a
certificate of registration. The duty to issue such
certificate is not ministerial and hence not compellable
by a petition for mandamus. (PRC vs De Guzman)
What are the qualifications candidates for board exams
must possess?
1. Filipino citizen/foreigner (who must prove that his
country allows reciprocal rights to Filipinos in practicing
medicine);
2. Good moral character;
3. Of sound mind;
4. Not convicted of a crime involving moral turpitude;
5. Must be a holder of the degree of doctor of medicine;
and
6. He must have completed a calendar year of technical
training known as internship
What constitutes the practice of medicine?
 - A person shall be considered as engaged in the practice
of medicine if he:
1. For compensation, fee, salary or reward
(CFSR) in any form paid to him directly or
through another, or even without the same,
physically examine any person, and diagnose,
treat, operate or prescribe (PeDTOP) any
remedy for human disease, injury, deformity,
physical, mental or psychological (DIDPMP)
condition or ailment, real or imaginary,
regardless of the value of the remedy
administered, prescribed or recommended;
2. By means of signs, cards, advertisements,
written or printed matter, or through the
radio, TV or any other means of
telecommunication, either offer or undertake
by any means or method to diagnose, treat,
operate or prescribe any remedy for any
human disease, injury, deformity, physical,
mental or psychological condition; and
3. Falsely use the title of MD after his name
What are the exceptions to Sec. 10 regarding acts
constituting practice of medicine?
1. Any medical student duly enrolled in an approved
medical college or school, or graduate under training,
serving without any professional fee in any government
or private hospital, provided that he render such
service under the direct supervision and control of a
registered physician;
2. Any legally registered dentist engaged exclusively in
the practice of dentistry; (c) any duly registered
masseur or physiotherapist, provided that he applies
massage or other physical means upon written order
or prescription of a duly registered physician, or
provided that such application of massage or physical
means shall be limited to physical or muscular
development;
3. Any duly registered masseur or physiotherapist,
provided that he applies massage or other physical
means upon written order or prescription of a duly
registered physician, or provided that such application
of massage or physical means shall be limited to
physical or muscular development; who fit artificial
limbs under the supervision of a registered physician.
4. Any duly registered optometrist who mechanically fits
or sells lenses, artificial eyes, limbs or other similar
appliances or who is engaged in the mechanical
examination of eyes for the purpose of constructing or
adjusting eyeglasses, spectacles and lenses;
5. Any person who renders any service gratuitously in
cases of emergency, or in places where the services of
a duly registered physician, nurse or midwife are not
available;
6. Any person who administers or recommends any
household remedy as per classification of existing
Pharmacy Laws;
7. Any clinical psychologist, or mental hygienist, in the
performance of his duties in regard to patients with
psychiatric problems, provided such performance is
done with the prescription and direct supervision of a
duly registered physician, and
8. Prosthetists who fit artificial limbs under the
supervision of a registered physician.
What are the instances wherein a certificate of
registrations is not required?
1. Physicians and surgeons from other countries called in
consultation only and exclusively in specific and
definite case, or those attached to international bodies
or organizations assigned to perform certain definite
work in the Philippines, provided they shall limit their
practice to the specific work assigned to them and
provided further they shall secure a previous
authorization from the Board of Medical Examiners;
2. Commissioned medical officers of the United States
Armed Forces stationed in the Philippines while
rendering service as such only for the members of the
said armed forces and within the limit of their own
respective territorial jurisdiction;
3. Foreign physicians employed as exchange professors
in special branches of medicine or surgery whose
service may, upon previous authorization of the Board
of Medical Examiners, be necessary;
4. Medical students who have completed the first four
years of medical course, graduates of medicine and
registered nurses who may be given limited and special
authorization by the Secretary of Health to render
services during epidemics or national emergencies
whenever the services of duly registered physicians are
not available. Such authorization shall automatically
cease when the epidemic or national emergency is
declared terminated by the Secretary of Health.
What are the qualifications to be a member of the Board
of Medicine and how are they appointed?
- He must be:
1. A natural born Filipino citizen;
2. A physician practicing for at least 10 years;
3. One who is of good moral character and of
good standing in the medical profession;
4. Not a member of any medical school nor has
a pecuniary interest, directly or indirectly in
any medical school
- The Board of Medicine shall be composed of six
members to be appointed by the President of the
Philippines from a list of not more than twelve names
approved and submitted by the Executive Council of
the Philippine Medical Association, after due
consultation with other medical association during the
month of September each year. The chairman of the
Board shall be elected from among themselves by the
members at a meeting called for the purpose. The
President of the Philippines shall fill any vacancy that
may occur during any examination from the list of
names submitted by the Philippine Medical Association
in accordance with the provisions of this Act.
What are the duties of the Board of Medicine?
- They promulgate rules and regulations, subject to the
approval of the CSC, as may be necessary for the
proper conduct of exams, correction of exam papers,
and registration of physicians;
- Administer oaths to physicians;
- Study conditions affecting the practice of medicine in
the Philippines;
- Exercise powers conferred by law with the view of
maintaining the ethical and professional standards of
the medical profession;
 - Subpoena testifcandum / duces tecum; and
- Promulgate rules and regulations as may be necessary
What are the grounds for the reprimand, suspension or
revocation of a physician’s certificate of registration?
1. Conviction by a court of competent jurisdiction of any
criminal offense involving moral turpitude;
2. Immoral or dishonorable conduct;
3. Insanity;
4. Fraud in the acquisition of the certificate of
registration;
5. Gross negligence, ignorance or incompetence in the
practice of his or her profession resulting in an injury
to or death of the patient;
6. Addiction to alcoholic beverages or to any habit
forming drug rendering him or her incompetent to
practice his or her profession, or to any form of
gambling;
7. False or extravagant or unethical advertisements
wherein other things than his name, profession,
limitation of practice, clinic hours, office and home
address, are mentioned.
8. Performance of or aiding in any criminal abortion;
9. Knowingly issuing any false medical certificate;
10. Issuing any statement or spreading any news or rumor
which is derogatory to the character and reputation of
another physician without justifiable motive;
11. Aiding or acting as a dummy of an unqualified or
unregistered person to practice medicine;
12. Violation of any provision of the Code of Ethics as
approved by the Philippine Medical Association.
*Refusal of a physician to attend a patient in danger of
death is not a sufficient ground for revocation or
suspension of his registration certificate if there is a risk
to the physician's life.
What are the procedures to observe in case of
administrative investigations by the Board of Medicine?
- Within five days after the filling of written charges
under oath, the respondent physician shall be
furnished a copy thereof, without requiring him or her
to answer the same, and the Board shall conduct the
investigation within five days after the receipt of such
copy by the respondent. The investigation shall be
completed as soon as practicable.
- Administrative investigations must be conducted by at
least two members of the Board of Medicine, with one
legal officer sitting during the investigation.
- The respondent physician shall be entitled to be
represented by counsel or be heard by himself or
herself, to have a speedy and public hearing, to
confront and to cross-examine witnesses against him
or her, and to all other rights guaranteed by the
Constitution and provided for in the Rules of Court.
- The decision of the Board of Medical Examiners shall
automatically become final thirty days after the date of
its promulgation unless the respondent, during the
same period, has appealed to the Commissioner of Civil
Service and later to the Office of the President of the
Philippines. If the final decision is not satisfactory, the
respondent may ask for a review of the case, or may
file in court a petition for certiorari.
- After two years, the Board may order the
reinstatement of any physicians whose certificate of
registration has been revoked, if the respondent has
acted in an exemplary manner in the community
wherein he resides and has not committed any illegal,
immoral or dishonorable act.
Liabilities of a Physician
What are the three fold liabilities of a physician?
- (1) Administrative, (2) Civil, and (3) Criminal
Do the regular courts have the authority to suspend or
revoke the license of a physician?
- No, it is the Board of Medicine that is vested with such
authority.
- Administrative complaints against an erring physician
must be filed with the Board of Medicine.
Can the Board of Medicine imprison or impose a fine on
an erring physician?
- No. Only the regular courts can do that.
What are the duties of physician under the PMA Code of
Ethics?
1. A physician should be dedicated to provide competent
medical care with full professional skill in accordance
with the current standards of care, compassion,
independence and respect for human dignity.
2. A physician should be free to choose patients.
 Rationale: You cannot force a doctor to
examine a patient whose illness is not within
his competence.
3. In an emergency, provided there is no risk to his or her
safety, a physician should administer at least first aid
treatment and then refer the patient to the primary
physician and/or to a more competent health provider
and appropriate facility if necessary.
 Elements:
i. There must be an emergency; and
ii. There must be no risk to the
physician’s safety.
4. In serious/difficult cases, or when the circumstances of
the patient or the family so demand or justify, the
attending physician should seek the assistance of the
appropriate specialist.
 ‘Wag dapat ma-pride. Pag hindi kaya, humingi
ng tulong.
5. A physician should exercise good faith and honesty in
expressing opinion/s as to the diagnosis, prognosis,
and treatment of a case under his/her care. A physician
shall respect the right of the patient to refuse medical
treatment. Timely notice of the worsening of the
disease should be given to the patient and/or family. A
physician shall not conceal nor exaggerate the patient’s
condition except when it is to the latter’s best interest.
A physician shall obtain from the patient a voluntary
informed consent. In case of unconsciousness or in a
state of mental deficiency the informed consent may
be given by a spouse or immediate relatives and in the
absence of both, by the party authorized by an
advanced directive of the patient. Informed consent in
the case of minor should be given by the parents or
guardian, members of the immediate family that are of
legal age.
 Good faith and honest opinion;
  Respect the right of the patient to refuse
medical treatment;
 Give timely notice of the worsening of the
disease;
 Must not conceal nor exaggerate the patient’s
condition, except when it is to the latter’s best
interest; and
 Voluntary informed consent.
6. The physician should hold as sacred and highly
confidential whatever may be discovered or learned
pertinent to the patient even after death, except when
required in the promotion of justice, safety and public
health.
7. Professional fees should be commensurate to the
services rendered with due consideration to the
patient’s financial status, nature of the case, time
consumed and the professional standing and skill of the
physician in the community
Can an aggrieved patient institute administrative, civil
and criminal actions against a physician
simultaneously?
- Yes, there is no prohibition to that effect.
What is the remedy of a party from an unfavorable
decision of the Board of Medicine?
- Board of Medicine  PRC  (via Rule 43) CA  (via
Rule 45)  SC
What are the elements of Medical Negligence?
1.
There must be a Doctor-Patient Relationship;
2.
There must be a duty;
3.
There is a breach of such duty;
4.
Damage to the patient resulted from that breach;
and
5. The breach must be the proximate cause of the
damage to the patient;
 Jurisprudence:
 If the proximate cause of the patient’s
damage was his own failure to heed the
instructions of his doctor, there is no medical
negligence. (Lasam vs Ramolete, 2008)
What is the usual if not the only cause of action against
a doctor in a civil suit?
- Art. 2176 of the Civil Code: “Article 2176. Whoever by
act or omission causes damage to another, there being
fault or negligence, is obliged to pay for the damage
done. Such fault or negligence, if there is no pre-
existing contractual relation between the parties, is
called a quasi-delict and is governed by the provisions
of this Chapter.”
Cite instances where there is no Doctor-Patient
relationship?
- Company doctor set-up, pre-employment check ups,
insurance, where physician is forced by the court to
examine a patient.
How can a plaintiff or complainant prove the breach of
duty and the proximate causation?
- He needs to procure a testimony of an expert witness.
- Expert witnesses are very important in medical
negligence cases. They have therein a two-fold role:
1. To establish the standard of care; and
2. To state whether or not the defendant
physician has followed such proper standard
of care.
 Jurisprudence:
 To be sure, the Court cannot give much
weight to the complainant’s own opinion and
assessment of what the doctor should have
and should not have done. (Lucas vs Tuano,
2009)
How can a physician qualify to testify as an expert
witness?
- The Supreme Court had been consisted in ruling that
the doctor must be a specialist in the case concerned.
- But in Casumpang vs Cortejo (2015), the Court ruled
that to qualify a witness as a medical expert, it must
be shown that the witness:
1. Has the required professional knowledge,
learning and skill of the subject under inquiry
sufficient to qualify him to speak with
authority on the subject; and
2. Is familiar with the standard required of a
physician under similar circumstances;
Where a witness has disclosed sufficient
knowledge of the subject to entitle his opinion to
go to the jury, the question of the degree of his
knowledge goes more to the weight of the
evidence than to its admissibility.
- Also, in Ramos vs CA (1999), the Court held: “Although
witness Cruz is not an anesthesiologist, she can very
well testify upon matters on which she is capable of
observing such as, the statements and acts of the
physician and surgeon, external appearances, and
manifest conditions which are observable by any one.
48 This is precisely allowed under the doctrine of res
ipsa loquitur where the testimony of expert witnesses
is not required. It is the accepted rule that expert
testimony is not necessary for the proof of negligence
in non-technical matters or those of which an ordinary
person may be expected to have knowledge, or where
the lack of skill or want of care is so obvious as to
render expert testimony unnecessary. We take judicial
notice of the fact that anesthesia procedures have
become so common, that even an ordinary person can
tell if it was administered properly. As such, it would
not be too difficult to tell if the tube was properly
inserted. This kind of observation, we believe, does not
require a medical degree to be acceptable. At any rate,
without doubt, petitioner's witness, an experienced
clinical nurse whose long experience and scholarship
led to her appointment as Dean of the Capitol Medical
Center School at Nursing, was fully capable of
determining whether or not the intubation was a
success. She had extensive clinical experience starting
as a staff nurse in Chicago, Illinois; staff nurse and
clinical instructor in a teaching hospital, the FEU-NRMF;
Dean of the Laguna College of Nursing in San Pablo
City; and then Dean of the Capitol Medical Center
School of Nursing.”
What is the principle of res ipsa loquitur and how is it
relevant in medical negligence?
- "Where the thing which causes injury is shown to be
under the management of the defendant, and the
accident is such as in the ordinary course of things does
not happen if those who have the management use
proper care, it affords reasonable evidence, in the
absence of an explanation by the defendant, that the
accident arose from want of care."
- The doctrine of [r]es ipsa loquitur as a rule of evidence
is peculiar to the law of negligence which recognizes
that prima facie negligence may be established without
direct proof and furnishes a substitute for specific proof
of negligence. The doctrine is not a rule of substantive
law, but merely a mode of proof or a mere procedural
convenience. The rule, when applicable to the facts
and circumstances of a particular case, is not intended
to and does not dispense with the requirement of proof
of culpable negligence on the party charged. It merely
determines and regulates what shall be prima facie
evidence thereof and facilitates the burden of plaintiff
of proving a breach of the duty of due care. The
doctrine can be invoked when and only when, under
the circumstances involved, direct evidence is absent
and not readily available.
- In other words, in the absence of direct evidence or a
testimony of an expert witness, the complainant’s
cause of action may be saved by the application of res
ipsa loquitur.
What are the elements of res ipsa loquitur in the context
of medical negligence?
1. The accident is of a kind which ordinarily does not
occur in the absence of someone's negligence;
2. It is caused by an instrumentality within the
exclusive control of the defendant or defendants;
and
3. The possibility of contributing conduct which
would make the plaintiff responsible is eliminated.
 Jurisprudence:
 “In the instant case, all the requisites for recourse
to the doctrine are present. First, the entire
proceedings of the caesarean section were under
the exclusive control of Dr. Batiquin. In this light,
the private respondents were bereft of direct
evidence as to the actual culprit or the exact cause
of the foreign object finding its way into private
respondent Villegas's body, which, needless to
say, does not occur unless through the
intersection of negligence. Second, since aside
from the caesarean section, private respondent
Villegas underwent no other operation which could
have caused the offending piece of rubber to
appear in her uterus, it stands to reason that such
could only have been a by-product of the
caesarean section performed by Dr. Batiquin.”
(Batiquin vs CA, 1996)
 “Relative to the case, res ipsa loquitor does not
apply since the circumstances that caused patient
Roy Jr.’s injury and the series of tests that were
supposed to be undergone by him to determine
the extent of the injury suffered were not under
the exclusive control of Drs. Jarcia and Bastan. It
was established that they are mere residents of
the Manila Doctors Hospital at that time who
attended to the victim at the emergency room.
While it may be true that the circumstances
pointed out by the courts below seem doubtless to
constitute reckless imprudence on the part of the
petitioners, this conclusion is still best achieved,
not through the scholarly assumptions of a layman
like the patient’s mother, but by the
unquestionable knowledge of expert witness/es.
As to whether the petitioners have exercised the
requisite degree of skill and care in treating patient
Roy, Jr. is generally a matter of expert opinion.”
(Jarcia vs People, 2012)
 Luz delivered Gerald to the care, custody and
control of his physicians for a pull-through
operation. Except for the imperforate anus, Gerald
was then of sound body and mind at the time of
his submission to the physicians. Yet, he
experienced bradycardia during the operation,
causing loss of his senses and rendering him
immobile. Hypoxia, or the insufficiency of oxygen
supply to the brain that caused the slowing of the
heart rate, scientifically termed as bradycardia,
would not ordinarily occur in the process of a
pullthrough operation, or during the
administration of anesthesia to the patient, but
such fact alone did not prove that the negligence
of any of his attending physicians, including the
anesthesiologists, had caused the injury. In fact,
the anesthesiologists attending to him had sensed
in the course of the operation that the lack of
oxygen could have been triggered by the vago-
vagal reflex, prompting them to administer
atropine to the patient. (Solidum vs People, 2014)
Discuss the liability of a hospital with respect to the acts
of its physicians.
1. If an Employer-Employee Relationship is established,
then the hospital, unless it can prove diligence of a
good father in the selection of employees, is solidarily
liable with the doctor by virtue of vicarious liability
under Article 2180 of the Civil Code.
 It should be noted that in light of recent
jurisprudence, it is almost impossible to prove
an employment relationship, because it is
recognized in this jurisdiction that the
relationship between a physician and a
hospital is merely contractual.
 Under the Schloendorff Doctrine, a physician,
even if employed by a hospital, is considered
an independent contractor, because of the
skill he exercises and the lack of control
exerted over his work. Under this doctrine,
hospitals are exempt from the application of
the respondeat superior principle for fault or
negligence committed by physicians in the
discharge of their profession.
2. There is, however, what is called as the Doctrine of
Apparent Authority or Doctrine of Ostensible Agency,
which would still allow the complainant to invoke the
hospital’s vicarious liability.
3. The hospital may also be held liable under the Doctrine
of Corporate Negligence.
Discuss the Doctrine of Apparent Authority.
 - Under the Doctrine of Apparent Authority, a hospital enforcement of adequate rules and policies that ensure
can be held vicariously liable for the negligent acts of quality care for its patients. Thus, in Tucson Medical
a physician providing care at the hospital, regardless of Center, Inc. v. Misevich, it was held that a hospital,
whether the physician is an independent contractor, following the doctrine of corporate responsibility, has
unless the patient knows, or should have known, that the duty to see that it meets the standards of
the physician is an independent contractor. responsibilities for the care of patients. Such duty
- Elements: includes the proper supervision of the members of its
1. The hospital, or its agent, acted in a manner medical staff. And in Bost v. Riley, the court concluded
that would lead a reasonable person to that a patient who enters a hospital does so with the
conclude that the individual who was alleged reasonable expectation that it will attempt to cure him.
to be negligent was an employee or agent of The hospital accordingly has the duty to make a
the hospital; reasonable effort to monitor and oversee the treatment
2. Where the acts of the agent create the prescribed and administered by the physicians
appearance of authority, the plaintiff must practicing in its premises.
also prove that the hospital had knowledge of
and acquiesced in them; and Discuss the Captain of the Ship Doctrine.
3. The plaintiff acted in reliance upon the
- Under the Doctrine of Captain of the Ship, it is the
conduct of the hospital or its agent, consistent
surgeon's responsibility to see to it that those under
with ordinary care and prudence.
him perform their task in the proper manner.
 Jurisprudence:
- Invocation of this doctrine against a doctor means that
 There is ample evidence that the hospital (PSI)
the liability of the doctor stems from the negligence of
held out to the patient (Natividad) that the doctor
supervising the other doctors performing their task
(Dr. Ampil) was its agent. Present are the two
under him—whether or not the “captain” doctor
factors that determine apparent authority: first,
himself was also negligent in the surgery.
the hospital's implied manifestation to the patient
- Although in the US, this doctrine is starting to be
which led the latter to conclude that the doctor
discarded, it is still well applicable here in the
was the hospital's agent; and second, the patient’s
Philippines (Ramos vs CA, 1999)
reliance upon the conduct of the hospital and the
doctor, consistent with ordinary care and Discuss the Doctrine of Informed Consent
prudence. (PSI vs Agana, 2010)
- A physician has a duty to disclose what a reasonably
Discuss the Doctrine of Corporate Negligence. prudent physician in the medical community in the
exercise of reasonable care would disclose to his
- Recent years have seen the doctrine of corporate
patient as to whatever grave risks of injury might be
negligence as the judicial answer to the problem of
incurred from a proposed course of treatment, so that
allocating hospital’s liability for the negligent acts of
a patient, exercising ordinary care for his own welfare,
health practitioners, absent facts to support the
and faced with a choice of undergoing the proposed
application of respondeat superior or apparent
treatment, or alternative treatment, or none at all, may
authority. Its formulation proceeds from the judiciary’s
intelligently exercise his judgment by reasonably
acknowledgment that in these modern times, the duty
balancing the probable risks against the probable
of providing quality medical service is no longer the
benefits.
sole prerogative and responsibility of the physician.
- Four essential elements a plaintiff must prove in a
The modern hospitals have changed structure.
malpractice suit based on the Doctrine of Informed
Hospitals now tend to organize a highly professional
Consent:
medical staff whose competence and performance
1. the physician had a duty to disclose material
need to be monitored by the hospitals commensurate
risks;
with their inherent responsibility to provide quality
2. he failed to disclose or inadequately disclosed
medical care.
those risks;
- The doctrine has its genesis in Darling v. Charleston
3. as a direct and proximate result of the failure
Community Hospital. There, the Supreme Court of
to disclose, the patient consented to
Illinois held that “the jury could have found a hospital
treatment she otherwise would not have
negligent, inter alia, in failing to have a sufficient
consented to; and
number of trained nurses attending the patient; failing
4. plaintiff was injured by the proposed
to require a consultation with or examination by
treatment.
members of the hospital staff; and failing to review the
- The gravamen in an informed consent case requires
treatment rendered to the patient.” On the basis of
the plaintiff to point to significant undisclosed
Darling, other jurisdictions held that a hospital’s
information relating to the treatment which would have
corporate negligence extends to permitting a physician
altered her decision to undergo it.
known to be incompetent to practice at the hospital.
 Jurisprudence:
With the passage of time, more duties were expected
 “When petitioner informed the respondents
from hospitals, among them: (1) the use of reasonable
beforehand of the side effects of chemotherapy
care in the maintenance of safe and adequate facilities
which includes lowered counts of white and red
and equipment; (2) the selection and retention of
blood cells, decrease in blood platelets, possible
competent physicians; (3) the overseeing or
kidney or heart damage and skin darkening, there
supervision of all persons who practice medicine within
is reasonable expectation on the part of the doctor
its walls; and (4) the formulation, adoption and
that the respondents understood very well that the
 severity of these side effects will not be the same
for all patients undergoing the procedure. In other
words, by the nature of the disease itself, each
patients reaction to the chemical agents even with
pre-treatment laboratory tests cannot be precisely
determined by the physician. That death can
possibly result from complications of the treatment
or the underlying cancer itself, immediately or
sometime after the administration of
chemotherapy drugs, is a risk that cannot be ruled
out, as with most other major medical procedures,
but such conclusion can be reasonably drawn from
the general side effects of chemotherapy already
disclosed.” (Li vs Sps Soliman, 2011)
What are some of the criminal offenses that may be
committed by a physician?
- Article 174. False medical certificates, false certificates
of merits or service, etc.
- Article 259. Abortion practiced by a physician or
midwife and dispensing of abortives
- Article 347. Simulation of births, substitution of one
child for another and concealment or abandonment of
a legitimate child.
- Criminal Negligence (Reckless Imprudence)
 Reckless imprudence consists in voluntary,
but without malice, doing or falling to do an
act from which material damage results by
reason of inexcusable lack of precaution on
the part of the person performing of failing to
perform such act, taking into consideration
his employment or occupation, degree of
intelligence, physical condition and other
circumstances regarding persons, time and
place.
 Simple imprudence consists in the lack of
precaution displayed in those cases in which
the damage impending to be caused is not
immediate nor the danger clearly manifest.
The Human Body1
Q: What is the significance of proper documentation of
injuries?
As far as lawyers are concerned, they rely on documents. It is
the best evidence. And it prevails over oral testimonies. Thus, if
there are discrepancies in the documents, it can destroy or
diminish the credibility of the witness.
Q: What do you do when you see a dead body lying
around?
a) Observe surroundings.
b) Examine the clothes.
 Look particularly for stains. If there’s a red
stain there, we do not immediately conclude
that it is blood. It might be a paint, ketchup,
etc. And if there is blood, we further qualify
whether it is human blood or not. The point
is, ‘wag assuming!
c) Try to ascertain identity of the person.
1 2
Find another source material for studying anatomy. I’m not
competent enough to make one.
 Interview people, but do not take their word
as gospel truth. Check for IDs, dog tags, etc.
 Know the gender of the person.
d) Identify the position of the dead body.
e) Identify the color of the person.
f) Ascertain the approximate time of death.
g) Check the orifices.
 Are there foreign objects, secretions, etc.?
Q: What is the different between a Post-Mortem
Examination and an Autopsy?
A post-mortem examination is limited to the orifices, while an
autopsy also examines the organs.
Note: In practice, both terms seem to be used interchangeably.
Q: What is the difference between a Medicolegal
Certificate and a Medical Certificate?
A medicolegal certificate is one issued by a medicolegal officer,
while a medical certificate is one issued by a physician. Both
have the same evidentiary value. But, the important thing to
remember is to make sure that the one who signs the certificate
is one authorized to document injuries.
Q: What are the two types of injuries?
1. Open; and
2. Closed
I. Closed Injuries are those which involve no tear on the skin.
Examples:
1. Fractures (which may also be open or closed
depending on whether there is a break on the skin);
a. Linear: a fracture that extends parallel to the
long axis of a bone but does not displace the
bone tissue
b. Comminuted (a fracture in which the bone
fragments into several pieces)
c. Greenstick (an incomplete fracture in which
the bone is bent. This type of fracture occurs
most often in children)2
d. Transverse: a fracture at a right angle to the
bone’s axis
e. Oblique: a fracture in which the break is at an
angle to the bone’s axis.
f. Impacted: one whose ends are driven into
each other.
2. Hematoma – Blood cyst/ commonly referred to as
“bukol”
3. Contusion – A bruise, or contusion, is caused when
blood vessels are damaged or broken as the result of
a blow to the skin3
Note: Be sure not to confuse hematoma with contusion. In
hematoma, you can extract the blood with a syringe, but you
cannot do that with contusion, because blood is scattered in
the tissues.
II. Open Wounds are injuries involving an external or
internal break in body tissue, usually involving the skin.
Examples:
Only the first three were discussed by Atty. Logronio
 1. Stab Wound It is also possible that there is only one bullet but more than one
 Caused by a sharp edge (e.g. knife, entrance wound. There are a lot of possibilities, given the
sword, etc.) advancement of technological warfare.
2. Perforated Wound
 Cause by a pointed instrument (e.g. ice Bullet movement is described to be any of the following:
pick, ball pen, etc.) spinning, tumbling and tail-wagging.
3. Lacerated Wound
Q: What are the differences between an entry wound
 Caused by a blunt instrument (e.g.
and an exit wound?
baseball bat, Manny Pacquio’s fists, etc.)
4. Incised Wound Entry Wound Exit Wound
 Caused by a sharp-edged object in 1. Usually round in shape. 1. No particular shape. (This
slashing or slicing motion. is why newbies usually make
5. Abrasion a mistake of considering this
 An abrasion is a wound caused by as a stab wound.)
superficial damage to the skin, no deeper 2. Inverted (papasok) 2. Everted (palabas)
than the epidermis. Also known as 3. You can find an 3. You can’t find them
“gasgas” abrasion/contusion collar
6. Gunshot Wound
 a form of physical trauma sustained from
the discharge of arms or munitions Q: What is an Abrasion Collar?
Q: What are the important differences between a When the bullet or projectile penetrates the epithelial tissue,
lacerated wound and an incised wound? there is friction between the skin and the projectile. This friction
results in an abraded area of tissue which surrounds the entry
Lacerated Wound Incised Wound wound and is known as an abrasion collar.4
1. Cut is clean 1. Cut is not clean
2. There is swelling 2. There is no swelling It is the gasgas caused by the bullet where the bullet is
3. There is no cut of hair 3. There is a cut of hair angulated which would make gasgas before making an entrance
4. Heals slower 4. Heals faster to the skin.

This is important for purposes of giving an idea as to the position

Q: What are the stuff that come out when you fire a gun? of the assailant when he fired the gun.

1. Bullet; Q: How do we document rape cases?

2. Flame (reaches up to 6 inches) - Singeing;
3. Smoke (reaches up to 12 inches) – Soot/Smudging;
4. Unburnt Powder (reaches up to 24 inches) –
Peppering/Stippling.
Q: What is the importance of knowing the stuff, aside
from bullets, that come from a gun?
The presence of one or more of them may be determinative of
the distance of the assailant. For example, if the gunshot
wound includes all the four, there is a high probability that the
assailant was very near when he fired the gun. Likewise, if it is
just a gunshot wound, then the assailant most likely fired from
a distance.
Q: What are the two types of gunshot wound (GSW)?
1. Entry Wound
2. Exit Wound
The usual scenario is that there are even numbers of GSW. This
is what is known as the “Odd-Even Rule.” So, if you were shot
thrice, there should be six GSW.
But of course, it is possible to have an odd number of GSW. In
such case, there would be a presumption that one or more
bullets are still inside the body.
First, we must look for injuries around the legs first and other
body parts (particularly the wrists), which would indicate that
rape was probably committed. For example: A struggling woman
being raped would usually sustain bruises in some of her body
parts.
In rape, there are usually hymenal lacerations which are
distinguished and determined by using the face of the clock:
1. Incomplete Laceration (around 3 o’clock)
2. Complete Laceration (around 6 o’clock onwards)
3. Compound Laceration (outside the hymen)
The healing period of hymenal laceration is from four to 10 days.
Q: How do we know that a person is already dead?
We can’t just say “Hindi na gumagalaw eh, kaya patay na.”
There are two machines that that determine whether a person
is already dead:
1. Electroencephalogram (EEG) – test that measures and
records the electrical activity of your brain. Special
sensors electrodes are attached to your head and
hooked by wires to a computer. The computer records
your brain's electrical activity on the screen or on paper
as wavy lines. Certain conditions, such as seizures, can
be seen by the changes in the normal pattern of the
brain's electrical activity.

4
http://what-when-how.com/forensic-sciences/evaluation-
of-gunshot-wounds/
 2. Electrocardiogram (ECG) - a test that records the
electrical activity of the heart. It is used to measure the
rate and regularity of heartbeats as well as the size and
position of the chambers, the presence of any damage
to the heart, and the effects of drugs or devices used
to regulate the heart (such as a pacemaker)
In the Philippines, it is the ECG that is commonly used, because
most hospitals cannot afford EEG machines.
Q: What are the vital signs of a person?
1. Blood Pressure
2. Respiratory Rate
3. Pulse Rate
4. Body Temperature
The first three are used to pronounce a person clinically dead.
Clinical death is the medical term for cessation of blood
circulation and breathing, the two necessary criteria to sustain
human and many other organisms' lives.[1] It occurs when the
heart stops beating in a regular rhythm, a condition called
cardiac arrest. The term is also sometimes used in resuscitation
research.
On the other hand, brain/biological death occurs four to six
minutes after clinical death. This is due to the fact that the heart
is the main pumping machine of the body, and without the blood
coming from the heart, the brain will gradually cease to function
until it achieves irreversible damage. This is when the doctor will
formally or legally declare that the person is dead as the
neurological damage to the person is really impossible to
reverse.
A person can be clinically dead but can still exist with the help
of artificial life support. This is the best time to consider the
option of organ donation. Technically, the patient is already
dead but the organs are still functioning. Once the life support
is taken off, the whole body will start to deteriorate and cease
its functions permanently. Brain death, either of the whole brain
or the brain stem, is used as a legal indicator of death in many
jurisdictions.5
Q: What are the three stages which the muscles of the
body pass through after death?
1. Primary Flacidity
2. Rigor Mortis
3. Secondary Flacidity
1. Primary Flacidity (usually happens within the first three (3)
hours after death)
At the moment of death, the muscles relax completely—a
condition called "primary flaccidity." The muscles then stiffen,
perhaps due to coagulation of muscle proteins or a shift in the
muscle's energy containers (ATP-ADP), into a condition known
as rigor mortis. All of the body's muscles are affected.6
2. Rigor Mortis (Usually happens 3 hours after death and lasts
up to 12 hours)
5 7
http://www.nursebuff.com/2012/01/clinical-death-versus-
brain-death-which-comes-first/
6
http://www.deathreference.com/Py-Se/Rigor-Mortis-and-
Other-Postmortem-Changes.html#ixzz3snOTsK51
This is a state of stiffening of muscles, sometimes with slight
shortening of fibers. Individual cell death takes place in this
stage. The body becomes completely rigid on the 12th hour:
Complete Rigor Mortis.
Rigor mortis begins within two to six hours of death, starting
with the eyelids, neck, and jaw. This sequence may be due to
the difference in lactic acid levels among different muscles,
which corresponds to the difference in glycogen levels and to
the different types of muscle fibers. Over the next four to six
hours, rigor mortis spreads to the other muscles, including those
in the internal organs such as the heart. The onset of rigor
mortis is more rapid if the environment is cold and if the
decedent had performed hard physical work just before death.
Its onset also varies with the individual's age, sex, physical
condition, and muscular build.7
3. Secondary Flacidity (24 – 36 hours later)
After being in this rigid condition for twenty-four to eighty-
four hours, the muscles relax and secondary laxity (flaccidity)
develops, usually in the same order as it began. The length of
time rigor mortis lasts depends on multiple factors, particularly
the ambient temperature. The degree of rigor mortis can be
determined by checking both the finger joints and the larger
joints and ranking their degree of stiffness on a one- to three-
or four-point scale. Many infant and child corpses will not exhibit
perceptible rigor mortis. This decreased perceptible stiffness
may be due to their smaller muscle mass. During this period,
the body gradually cools in a process called algor mortis. The
best way to accurately assess a corpse's temperature is with a
core (tympanic membrane, liver, or rectal) thermometer. Rectal
insertion may be difficult and cause postmortem injury.8
Q: What is Putrefaction?
During the Secondary Flacidity, body will also start to decay.
This is what is known as “Putrefaction.”
In the absence of embalming or relatively rapid cremation, the
body putrefies. The first sign of putrefaction is a greenish skin
discoloration appearing on the right lower abdomen about the
second or third day after death. This coloration then spreads
over the abdomen, chest, and upper thighs and is usually
accompanied by a putrid odor. Sulphur-containing intestinal gas
and a breakdown product of red blood cells produce both the
color and smell. The ancient Greeks and the Etruscans paid
homage to this well-recognized stage of decomposition by
coloring a prominent god aqua-marine, considered the color of
rotting flesh. Bacteria normally residing in the body, especially
the colon, play an important part in digestion of food during life.
They also contribute mightily to decomposition after death—the
process of putrefaction. The smell, rather than the sight, is the
most distinctive thing about a putrefying body. Under normal
conditions, the intestinal bacteria in a corpse produce large
amounts of foul-smelling gas that flows into the blood vessels
and tissues. It is this gas that bloats the body, turns the skin
from green to purple to black, makes the tongue and eyes
protrude, and often pushes the intestines out through the
vagina and rectum. The gas also causes large amounts of foul-
smelling bloodstained fluid to exude from the nose, mouth, and
other body orifices. Two of the chemicals produced during
Ibid.
8
Ibid.
putrefaction are aptly named putrescine (1,4-diaminobutane)
and cadaverine (1,5-pentanediamine). If a person dies from an
overwhelming bacterial infection, marked changes from
putrefaction can occur within as few as nine to twelve hours
after death. By seven days after death, most of the body is
discolored and giant blood-tinged blisters begin to appear. The
skin loosens and any pressure causes the top layer to come off
in large sheets (skin slip). As the internal organs and the fatty
tissues decay, they produce large quantities of foul-smelling gas.
By the second week after death, the abdomen, scrotum,
breasts, and tongue swell; the eyes bulge out. A bloody fluid
seeps out of the mouth and nose. After three to four weeks, the
hair, nails, and teeth loosen and the grossly swollen internal
organs begin to rupture and eventually liquefy. The internal
organs decompose at different rates, with the resistant uterus
and prostate often intact after twelve months, giving
pathologists one way to determine an unidentified corpse's sex.
Presence of maggots would indicate that the body has been
dead for more than 24 hours.9
Q: Discuss what happens when a person dies of
drowning?
The body tend to surface after 24 – 36 hours (during Secondary
Flacidity) because of putrefaction wherein the body becomes
bloated due to accumulation of gases.
Cadaveric spasm, also known as postmortem spasm,
instantaneous rigor, cataleptic rigidity, or instantaneous rigidity,
is a rare form of muscular stiffening that occurs at the moment
of death, persists into the period of rigor mortis and can be
mistaken for rigor mortis. The cause is unknown, but is usually
associated with violent deaths happening under extremely
physical circumstances with intense emotion.
It is usually used to determine whether injuries are suicidal or
homicidal. For example, when you shoot yourself with a
handgun, your wrist will stiffen. That is cadaveric spasm.
Q: When a person’s throat is cut, how do you know if it
is suicidal or homicidal?
1. Observe the angle and direction of the injury. In
suicide, the incision will be diagonal, while in homicide,
it will be horizontal.
2. In suicide, there will be what are known as “hesitance
cuts” (trial and error cuts), while in homicide, there is
usually only one cut.
3. In suicide, injury is usually above the Adam’s Apple,
while in homicide, it is below.
4. In suicide, there’s blood in front and in the hands, while
in homicide, there is blood at the back.

Q: If you find a dead body and it is still warm, what does

that tell you?

That it has been dead for probably less than three hours.

Q: If, during autopsy, food is found in the stomach, what

can you conclude?

It takes three hours for the stomach to vacate its contents. So,
you can conclude that the victim was killed less than three hours
ago.

Q: What happens when the heart stops pumping?

Lividity occurs. Lividity is the process through which the body's

blood supply will stop moving after the heart has stopped
pumping it around the inside of the deceased. What normally
happens at this point is that the blood supply - or at least any
blood that remains within the corpse depending on the nature
of their death - will settle in direct response to gravity. For
example an individual found lying on their stomach would be
found with all the blood from their back heading towards the
ground. Lividity also displays itself as a dark purple
discolouration of the body and can also be referred to as Livor
Mortis or Post Mortem Hypostasis.

It is worth noting that lividity begins to work through the

deceased within thirty minutes of their heart stopping and can
last up to twelve hours. Only up to the first six hours of death
can lividity be altered by moving the body. After the six hour
mark lividity is fixed as blood vessels begin to break down within
the body. Rigor mortis and lividity are some of the key factors
that are used when Estimating the Time of Death. 10

Q: What is Cadaveric Spasm?

9 10
Ibid. http://www.exploreforensics.co.uk/rigor-mortis-and-
lividity.html
 Frontal Lobe – Responsible for voluntary movement. If you
destroy this, the person would lose sense of movement.

Parietal Lobe – Responsible for sensation. Loss of sensation.

Magiging manhid ka.
Wound to the intestine? Expect food materials to spill out.
Cerebellum – Responsible for balance/equilibrium. Ito yung
Wound to the stomach? Expect spillage of acid, which could also naapektuhan, pag naglasing ka.
destroy other organs.
Brain Stem – Connected to vital sectors.
Wound to the large intestine? Expect spillage of fecal materials,
which may cause the person to die due to infection.

One of the purposes of the circulatory system is to deliver

nutrients, extraction of waste materials, deliver oxygen.
Circulatory

Two types of blood vessels: artery and veins. What is the

difference? Artery (high pressure) releases oxygen (away from
the heart to the different parts of the body). Vein (low pressure)
carries blood going back to the heart. Artery usually located
deeper. Pulses are in the artery not in veins.

Injury to the artery? Blood will spur out. Injury to the vein?
Blood will pour out.

Thank God liver and artery are hidden deep within the body.
Because you can die instantly if those are injured.

Brain
UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
*use at your own risk*

Medical Malpractice Physician-Patient Relationship

- No exact law, BASIS: Civil Code - contractual in nature
“Art. 2176. Whoever by act or omission causes - Implied consent
damage to another, there being fault or negligence, - contract may be oral or written
is obliged to pay for the damage done. Such fault or - inferred from the acts of the parties
negligence, if there is no pre-existing contractual
relation between the parties, is called a quasi-delict The Human Body
and is governed by the provisions of this Chapter.” Anatomic Position - palm face forward

“Art. 2179. When the plaintiff's own negligence was

the immediate and proximate cause of his injury, he
cannot recover damages. But if his negligence was
only contributory, the immediate and proximate
cause of the injury being the defendant's lack of due
care, the plaintiff may recover damages, but the
courts shall mitigate the damages to be awarded”

“Art. 2180. The obligation imposed by Article 2176 is

demandable not only for one's own acts or
omissions, but also for those of persons for whom
one is responsible.
The father and, in case of his death or
incapacity, the mother, are responsible for the
damages caused by the minor children who live in
their company.
Guardians are liable for damages caused by
the minors or incapacitated persons who are under
their authority and live in their company.
The owners and managers of an
establishment or enterprise are likewise responsible
for damages caused by their employees in the service
of the branches in which the latter are employed or
on the occasion of their functions. Head
Employers shall be liable for the damages 1. Parietal - top
caused by their employees and household helpers 2. Frontal - forehead
acting within the scope of their assigned tasks, even 3. Orbit - eyeball
though the former are not engaged in any business 4. Temporal - sides
or industry. 5. Zygomatic area - cheeks
The State is responsible in like manner when 5.1. maxilla - upper teeth
it acts through a special agent; but not when the 5.2. mandible - lower teeth
damage has been caused by the official to whom the *occipital - back (batok)
task done properly pertains, in which case what is 6. Hands
provided in Article 2176 shall be applicable. Fingers = digits
Lastly, teachers or heads of establishments Digit #1 - thumb
of arts and trades shall be liable for damages caused Trunk
by their pupils and students or apprentices, so long 7. Chest Area
as they remain in their custody. 7.1. Anterior - front
The responsibility treated of in this article 7.2. Posterior - back
shall cease when the persons herein mentioned 7.3. Lateral - sides
prove that they observed all the diligence of a good *Number of Ribs - 12
father of a family to prevent damage. Rib #1 - underneath the clavicle
Rib #2 - start counting
Line at the center is your landmark

1
UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
*use at your own risk*

8. Abdominal (umbilicus is the landmark) Teresita did not return the next week as
Quadrant advised. However, when her condition persisted, she
went to further consult Dr. Flores at his UDMC clinic.
When Dr. Fredelicto arrived, he did a routine check-
up and ordered Teresita's admission to the hospital.
In the admission slip, he directed the hospital staff to
prepare the patient for an "on call" D&C5 operation
to be performed by his wife, Dr. Felicisima Flores (Dr.
Felicisima). Teresita was brought to her hospital
Back room at around 12 noon; the hospital staff forthwith
Lumbar Area took her blood and urine samples for the laboratory
Upper back/ Lower back tests which Dr. Fredelicto ordered.
On the same day, Teresita was taken to the
Limbs operating room. It was only then that she met Dr.
9. Arm Felicisima, an obstetrician and gynecologist. The two
9.1 .anterior - front doctors - Dr. Felicisima and Dr. Fredelicto, conferred
9.2. posterior - back on the patient's medical condition, while the
9.3. medial - middle resident physician and the medical intern gave Dr.
10. Forearm Felicisima their own briefings. She also interviewed
10.1 .anterior - front and conducted an internal vaginal examination of
10.2. posterior - back the patient which lasted for about 15 minutes. Dr.
10.3. medial - middle Felicisima thereafter called up the laboratory for the
results of the tests. At that time, only the results for
11. Thigh (same as above) the blood sugar (BS), uric acid determination,
12. Leg (same as above) cholesterol determination, and complete blood
13. Foot count (CBC) were available. Teresita's BS count was
Toes = digits 10.67mmol/l7 and her CBC was 109g/l.8
Digit #1 - big toe Based on these preparations, Dr. Felicisima
proceeded with the D&C operation with Dr.
Vital Organs Fredelicto administering the general anesthesia. A
Brain day after the operation, Teresita was subjected to an
Heart ultrasound examination as a confirmatory
Lungs procedure. The results showed that she had an
enlarged uterus and myoma uteri. Dr. Felicisima,
however, advised Teresita that she could spend her
MEDICAL NEGLIGENCE CASES recovery period at home. Still feeling weak, Teresita
opted for hospital confinement. Teresita's complete
1. Sps. Flores vs. Sps. Pineda laboratory examination results came only on that
FACTS: day . Teresita's urinalysis showed a three plus sign
Teresita Pineda consulted Dr. Fredelicto (+++) indicating that the sugar in her urine was very
Flores, regarding her medical condition. She high. She was then placed under the care of Dr.
complained of general body weakness, loss of Amado Jorge, an internist.
appetite, frequent urination and thirst, and on-and- Teresita's condition had worsened. She
off vaginal bleeding. Dr. Fredelicto initially experienced difficulty in breathing and was rushed
interviewed the patient and asked for the history of to the intensive care unit. Further tests confirmed
her monthly period to analyze the probable cause of that she was suffering from Diabetes Mellitus Type
the vaginal bleeding. He advised her to return the II. Insulin was administered on the patient, but the
following week or to go to the United Doctors medication might have arrived too late. Due to
Medical Center (UDMC) in Quezon City for a general complications induced by diabetes, Teresita died.
check-up. As for her other symptoms, he suspected Believing that Teresita's death resulted
that Teresita might be suffering from diabetes and from the negligent handling of her medical needs,
told her to continue her medications. her family (respondents) instituted an action for
damages against Dr. Fredelicto Flores and Dr.

2
UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
*use at your own risk*
Felicisima Flores (collectively referred to as the
petitioner spouses) before the RTC of Nueva Ecija.
The RTC ruled in favor of Teresita's family
and awarded actual, moral, and exemplary damages,
plus attorney's fees and costs. The CA affirmed the
judgment, but modified the amount of damages
awarded and deleted the award for attorney's fees
and costs of suit.
ISSUE:
W/N the doctors were liable through
negligence for the death of the patient?
RULING: Yes. Decision of the RTC and CA affirmed.
RATIO
Elements of a Medical Negligence Case
A medical negligence case is a type of claim to
redress a wrong committed by a medical
professional, that has caused bodily harm to or the
death of a patient. There are four elements involved
in a medical negligence case, namely: duty, breach,
injury, and proximate causation
Duty refers to the standard of behavior which
imposes restrictions on one's conduct. The standard
in turn refers to the amount of competence
associated with the proper discharge of the
profession. A physician is expected to use at least
the same level of care that any other reasonably
competent doctor would use under the same
circumstances. Breach of duty occurs when the
physician fails to comply with these professional
standards. If injury results to the patient as a result
of this breach, the physician is answerable for
negligence.
As in any civil action, the burden to prove the
existence of the necessary elements rests with the
plaintiff. To successfully pursue a claim, the plaintiff
must prove by preponderance of evidence that
1. the physician either failed to do something which
a reasonably prudent health care provider would
have done, or that he did something that a
reasonably prudent provider would not have done;
2. the failure or action caused injury to the patient.
Expert testimony is therefore essential since the
factual issue of whether a physician or surgeon has
exercised the requisite degree of skill and care in the
treatment of his patient is generally a matter of
expert opinion.
As previously mentioned, 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;
the plaintiff must plead and prove not only that he
had been injured and defendant has been at fault,
but also that the defendant's fault caused the injury.
A verdict in a malpractice action cannot be based on
speculation or conjecture. Causation must be proven
within a reasonable medical probability based upon
competent expert testimony.
In the present case, there was a duty on the part of
the Doctors to exercise the standard of care in
performing surgery on a patient with diabetes. There
was a breach of that duty when they decided to
proceed with the D&C operation (raspa),
notwithstanding Teresita's hyperglycemia and
without adequately preparing her for the procedure.
It contrary to the standards observed by the medical
profession. Deviation from this standard amounted
to a breach of duty which resulted in the patient's
death. Due to this negligent conduct, liability must
attach to the petitioner spouses.
2. Cruz vs. CA
FACTS
Lydia Umali was Diagnosed by Dr. Cruz to
have a myoma in her uterus and scheduled her for a
hysterectomy operation. According to Rowena
(Lydia’s daughter), she noticed that the clinic was
untidy and the window and the floor were very
dusty prompting her to ask the attendant for a rag to
wipe the window and the floor with. Because of the
untidy state of the clinic, Rowena tried to persuade
her mother not to proceed with the operation. The
following day, before her mother was wheeled into
the operating room, Rowena asked Dr. Cruz if the
operation could be postponed. Dr. Cruz called Lydia
into her office and the two had a conversation. Lydia
then informed Rowena that the petitioner told her
that she must be operated on as scheduled.
Rowena and her other relatives, namely her
husband, her sister and two aunts waited outside
the operating room while Lydia underwent
operation. While they were waiting, Dr. Ercillo
(anaesthesiologist) went out of the operating room
and instructed them to buy tagamet ampules which
Rowena's sister immediately bought. About one
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hour had passed when Dr. Ercillo came out again this
time to ask them to buy blood for Lydia. They bought
type "A" blood from the St. Gerald Blood Bank and
the same was brought by the attendant into the
operating room. After the lapse of a few hours, Dr.
Cruz informed them that the operation was finished.
The operating staff then went inside the petitioner's
clinic to take their snacks. Some thirty minutes after,
Lydia was brought out of the operating room in a
stretcher and the petitioner asked Rowena and the
other relatives to buy additional blood for Lydia.
Unfortunately, they were not able to comply with
petitioner's order as there was no more type "A"
blood available in the blood bank. Thereafter, a
person arrived to donate blood which was later
transfused to Lydia. Rowena then noticed her
mother, who was attached to an oxygen tank,
gasping for breath. Apparently the oxygen supply
had run out and Rowena's husband together with
the driver of the accused had to go to the San Pablo
District Hospital to get oxygen. Lydia was given the
fresh supply of oxygen as soon as it arrived. But at
around 10:00 o'clock P.M. she went into shock and
her blood pressure dropped to 60/50. Lydia's
unstable condition necessitated her transfer to the
San Pablo District Hospital so she could be
connected to a respirator and further examined. The
transfer to the San Pablo District Hospital was
without the prior consent of Rowena nor of the
other relatives present who found out about the
intended transfer only when an ambulance arrived
to take Lydia to the San Pablo District Hospital.
Rowena and her other relatives then boarded a
tricycle and followed the ambulance.
Upon Lydia's arrival at the San Pablo District
Hospital, she was wheeled into the operating room
and the petitioner and Dr. Ercillo re-operated on her
because there was blood oozing from the abdominal
incision. The attending physicians summoned Dr.
Bartolome Angeles, head of the Obstetrics and
Gynecology Department of the San Pablo District
Hospital. However, when Dr. Angeles arrived, Lydia
was already in shock and possibly dead as her blood
pressure was already 0/0. Dr. Angeles then informed
petitioner and Dr. Ercillo that there was nothing he
could do to help save the patient. While Dr. Cruz was
closing the abdominal wall, the patient died. Thus,
on March 24, 1991, at 3:00 o'clock in the morning,
Lydia Umali was pronounced dead.
Dr. Cruz was charged with reckless
imprudence and negligence resulting to homicide.
The MTC, RTC and CA found Dr. Cruz guilty. Hence
this petition.
ISSUE:
W/N petitioner's conviction of the crime of
reckless imprudence resulting in homicide, arising
from an alleged medical malpractice, is supported by
the evidence on record.
RULING:
Petitioner is hereby ACQUITTED of the
crime of reckless imprudence resulting in homicide
but is ordered to pay the heirs of the deceased Lydia
Umali the amount of P50,000.00 as civil liability,
P100,000.00 as moral damages, and P50,000.00 as
exemplary damages.
RATIO:
The elements of reckless imprudence are:
(1) that the offender does or fails to do an act; (2)
that the doing or the failure to do that act is
voluntary; (3) that it be without malice; (4) that
material damage results from the reckless
imprudence; and (5) 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.
Whether or not a physician has committed
an "inexcusable lack of precaution" in the treatment
of his patient is 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.
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,
inasmuch 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 support
the conclusion as to causation.
In order that there may be a recovery for an
injury, however, it must be shown that the "injury
for which 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." In other words, the
negligence must be the proximate cause of the
injury. For, "negligence, no matter in what it
consists, cannot create a right of action unless it is
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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 not have occurred."
This Court has no recourse but to rely on
the expert testimonies rendered by both
prosecution and defense witnesses that substantiate
rather than contradict petitioner's allegation that
the cause of Lydia's death was DIC which, as attested
to by an expert witness, cannot be attributed to the
petitioner's fault or negligence. The probability that
Lydia's death was caused by DIC was unrebutted
during trial and has engendered in the mind of this
Court a reasonable doubt as to the petitioner's guilt.
Thus, her acquittal of the crime of reckless
imprudence resulting in homicide. While we condole
with the family of Lydia Umali, our hands are bound
by the dictates of justice and fair dealing which hold
inviolable the right of an accused to be presumed
innocent until proven guilty beyond reasonable
doubt. Nevertheless, this Court finds the petitioner
civilly liable for the death of Lydia Umali, for while a
conviction of a crime requires proof beyond
reasonable doubt, only a preponderance of evidence
is required to establish civil liability.
The petitioner is a doctor in whose hands a
patient puts his life and limb. For insufficiency of
evidence this Court was not able to render a
sentence of conviction but it is not blind to the
reckless and imprudent manner in which the
petitioner carried out her duties. A precious life has
been lost and the circumstances leading thereto
exacerbated the grief of those left behind. The heirs
of the deceased continue to feel the loss of their
mother up to the present time and this Court is
aware that no amount of compassion and
commiseration nor words of bereavement can
suffice to assuage the sorrow felt for the loss of a
loved one. Certainly, the award of moral and
exemplary damages in favor of the heirs of Lydia
Umali are proper in the instant case.
3. Carillo vs. Ppl
FACTS
The deceased, Catherine Acosta, a 13 year
old girl, daughter of spouses Domingo and Yolanda
Acosta, complained to her father of pains in the
lower part of her abdomen. Catherine was then
brought to Peña. Dra. Peña called for Dr. Madrid and
the latter examined Catherine Acosta. According to
Dr. Madrid, his findings might be appendicitis. Then
Dr. Peña told Catherine's parents to bring the child
to the hospital in Baclaran so that the child will be
observed.
At the Baclaran General Hospital, the child
was scheduled for operation at 5:00 o'clock in the
afternoon. The operation took place at 5:45 p.m.
because Dr. Madrid arrived only at that time.
It has also been established that the
deceased was not weighed before the
administration of anesthesia on her.
The operation was finished at 7:00 o'clock
in the evening and when the child was brought out
from the operating room, she was observed to be
shivering (nanginginig); her heart beat was not
normal; she was asleep and did not wake up; she
was pale; and as if she had difficulty in breathing and
Dr. Emilio Madrid suggested that she placed under
oxygen tank; that oxygen was administered to the
child when she was already in the room.
Witness Yolanda Acosta further testified
that shortly before the child was transferred from
the operating room to her room, she (witness) was
requested by the anesthesiologist to go home and
get a blanket.
When Catherine remained unconscious
until noontime the next day, a neurologist examined
her and she was diagnosed as comatose. Three (3)
days later, Catherine died without regaining
consciousness.
The Court of Appeals held that Catherine
had suffered from an overdose of, or an adverse
reaction to, anesthesia, particularly the arbitrary
administration of Nubain, a pain killer, without
benefit of prior weighing of the patient's body mass,
which weight determines the dosage of Nubain
which can safely be given to a patient. The Court of
Appeals held that this condition triggered off a heart
attack as a post-operative complication, depriving
Catherine's brain of oxygen, leading to the brain's
hemorrhage. The Court of Appeals identified such
cardiac arrest as the immediate cause of Catherine's
death.
The RTC and the CA found that there was criminal
negligence on the part of Dr. Carillo and Dr. Madrid.
ISSUE:
W/N the finding of facts of the CA
adequately support the conclusion that both doctors
are guilty of simple negligence which resulted in
homicide?
RULING:
Decision of the CA is affirmed.
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RATIO:
The gravamen of the offense of simple negligence is
the failure to exercise the diligence necessitated or
called for the situation which was not immediately
life-destructive but which culminated, in the present
case, in the death of a human being three (3) days
later. Such failure to exercise the necessary degree
of care and diligence is a negative ingredient of the
offense charged. The rule in such cases is that while
the prosecution must prove the negative ingredient
of the offense, it needs only to present the best
evidence procurable under the circumstances, in
order to shift the burden of disproving or countering
the proof of the negative ingredient to the accused,
provided that such initial evidence establishes at
least on a prima facie basis the guilt of the accused.
This rule is particularly applicable where the
negative ingredient of the offense is of such a nature
or character as, under the circumstances, to be
specially within the knowledge or control of the
accused. In the instant case, the Court is bound to
observe that the events which occurred during the
surgical procedure (including whether or not Nubain
had in fact been administered as an anesthesia
immediately before or during the surgery) were
peculiarly within the knowledge and control of Dr.
Carillo and Dr. Madrid. It was, therefore, incumbent
upon the two (2) accused to overturn the prima facie
case which the prosecution had established, by
reciting the measures which they had actually taken
to prevent or to counter the obviously serious
condition of Catherine Acosta which was evident
right after surgery. This they failed or refused to do
so.
Still another circumstance of which account
must be taken is that both petitioner and Dr. Madrid
failed to inform the parents of their minor patient of
the nature of her illness, or to explain to them either
during the surgery
(if feasible) or at any time after the surgery, the
events which comprised the dramatic deterioration
of her condition immediately after surgery as
compared with her pre-surgery condition. To give a
truthful explanation to the parents was a duty
imposed upon them by the canons of their
profession. Petitioner should have explained to
Catherine's parents the actual circumstances
surrounding Catherine's death, how, in other words,
a simple appendectomy procedure upon an
ambulatory patient could have led to such fatal
consequences.
By way of resume, in the case at bar, we
consider that the chain of circumstances above
noted, namely: (1) the failure of petitioner and Dr.
Madrid to appreciate the serious post-surgery
condition of their patient and to monitor her
condition and provide close patient care to her; (2)
the summons of petitioner by Dr. Madrid and the
cardiologist after the patient's heart attack on the
very evening that the surgery was completed; (3) the
low level of care and diligence exhibited by
petitioner in failing to correct Dr. Madrid's
prescription of Nubain for post-operative pain; (4)
the extraordinary failure or refusal of petitioner and
Dr. Madrid to inform the parents of Catherine Acosta
of her true condition after surgery, in disregard of
the requirements of the Code of Medical Ethics; and
(5) the failure of petitioner and Dr. Madrid to prove
that they had in fact exercised the necessary and
appropriate degree of care and diligence to prevent
the sudden decline in the condition of Catherine
Acosta and her death three (3) days later, leads the
Court to the conclusion, with moral certainty, that
petitioner and Dr. Madrid were guilty of simple
negligence resulting in homicide.
4. Dr. Cantre vs. Sps. Go
FACTS
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 S. Go. Nora
gave birth to her fourth child, a baby boy. However,
after giving birth, Nora suffered profuse bleeding
inside her womb due to some parts of the placenta
which were not completely expelled from her womb
after delivery. Consequently, Nora suffered
hypovolemic shock, resulting in a drop in her blood
pressure to "40" over "0." Petitioner and 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
sphygmomanometer. While petitioner was
massaging Nora’s uterus for it to contract and stop
bleeding, she ordered a droplight 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 gaping
wound two and a half (2 ½) by three and a half (3 ½)
inches in the inner portion of her left arm, close to
the armpit. He asked the nurses what caused the
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injury. He was informed it was a burn. John David
filed a request for investigation. In response, Dr.
Rainerio S. Abad, the medical director of the
hospital, called petitioner and the assisting resident
physician to explain what happened. Petitioner said
the blood pressure cuff caused the injury.
After that, John David brought Nora to the
National Bureau of Investigation for a physical
examination, which was conducted by medico-legal
officer Dr. Floresto Arizala, Jr. The medico-legal
officer later testified that Nora’s injury appeared to
be a burn and that a droplight when placed near the
skin for about 10 minutes could cause such burn. He
dismissed the likelihood that the wound was caused
by a blood pressure cuff as the scar was not around
the arm, but just on one side of the arm.
Nora’s injury was referred to a plastic
surgeon at the Dr. Jesus Delgado Memorial Hospital
for skin grafting. Her wound was covered with skin
sourced from her abdomen, which consequently
bore a scar as well. About a year after, scar revision
had to be performed at the same hospital. The
surgical operation left a healed linear scar in Nora’s
left arm about three inches in length, the thickest
portion rising about one-fourth (1/4) of an inch from
the surface of the skin. The costs of the skin grafting
and the scar revision were shouldered by the
hospital.
Unfortunately, Nora’s arm would never be
the same. Aside from the unsightly mark, the pain in
her left arm remains. When sleeping, she has to
cradle her wounded arm. Her movements now are
also restricted. Her children cannot play with the left
side of her body as they might accidentally bump the
injured arm, which aches at the slightest touch.
Thus, respondent spouses filed a complaint
for damages in the RTC against petitioner, Dr. Abad,
and the hospital. The RTC ruled in favor of the
Spouses Go and on appeal, the CA affirmed the
decision of the RTC with modifications.
ISSUE
W/N petitioner is liable for the injury
suffered by respondent?
RULING:
Petition Denied. Ruling of the CA affirmed.
RATIO
The Hippocratic Oath mandates physicians
to give primordial consideration to the well-being of
their patients. If a doctor fails to live up to this
precept, he is accountable for his acts. This
notwithstanding, courts face a unique restraint in
adjudicating medical negligence cases because
physicians are not guarantors of care and, they
never set out to intentionally cause injury to their
patients. However, intent is immaterial in negligence
cases because where negligence exists 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 loquitur 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:
1. The accident is of a kind which ordinarily
does not occur in the absence of someone’s
negligence;
2. It is caused by an instrumentality within
the exclusive control of the defendant or
defendants; and
3. The possibility of contributing conduct
which would make the plaintiff responsible
is eliminated.
As to the first requirement, the gaping wound on
Nora’s arm is certainly not an ordinary occurrence in
the act of delivering a baby, far removed as the arm
is from the organs involved in the process of giving
birth. Such injury could not have happened unless
negligence had set in somewhere.
Second, whether the injury was caused by
the droplight or by the blood pressure cuff is of no
moment. Both instruments are deemed within the
exclusive control of the physician in charge under
the "captain of the ship" doctrine. This doctrine
holds the surgeon in charge of an operation liable for
the negligence of his assistants during the time when
those assistants are under the surgeon’s control. In
this particular case, it can be logically inferred that
petitioner, the senior consultant in charge during the
delivery of Nora’s baby, exercised control over the
assistants assigned to both the use of the droplight
and the taking of Nora’s blood pressure. Hence, the
use of the droplight and the blood pressure cuff is
also within petitioner’s exclusive control.
Third, the gaping wound on Nora’s left arm,
by its very nature and considering her condition,
could only be caused by something external to her
and outside her control as she was unconscious
while in hypovolemic shock. Hence, Nora could not,
by any stretch of the imagination, have contributed
to her own injury.
Petitioner’s defense that Nora’s wound was
caused not by the droplight but by the constant
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taking of her blood pressure, even if the latter was
necessary given her condition, does not absolve her
from liability. As testified to by the medico-legal
officer, Dr. Arizala, Jr., the medical practice is to
deflate the blood pressure cuff immediately after
each use. Otherwise, the inflated band can cause
injury to the patient similar to what could have
happened in this case. Thus, if Nora’s wound was
caused by the blood pressure cuff, then the taking of
Nora’s blood pressure must have been done so
negligently as to have inflicted a gaping wound on
her arm, for which petitioner cannot escape liability
under the "captain of the ship" doctrine.
Further, petitioner’s argument that the failed plastic
surgery was not intended as a cosmetic procedure,
but rather as a measure to prevent complication
does not help her case. It does not negate
negligence on her part.
Based on the foregoing, the presumption
that petitioner was negligent in the exercise of her
profession stands unrebutted. In this connection, the
Civil Code provides:
ART. 2176. Whoever by act or omission causes
damage to another, there being fault or negligence,
is obliged to pay for the damage done.…
ART. 2217. Moral damages include physical
suffering, mental anguish, fright, serious anxiety,
besmirched reputation, wounded feelings, moral
shock, social humiliation, and similar injury. Though
incapable of pecuniary computation, moral damages
may be recovered if they are the proximate result of
the defendant’s wrongful act or omission.
Clearly, under the law, petitioner is obliged
to pay Nora for moral damages suffered by the latter
as a proximate result of petitioner’s negligence.
5. Batiquin vs. CA
FACTS
Mrs. Villegas is a married woman who
submitted to Dr. Batiquin for prenatal care as the
latter's private patient.
Dr. Batiquin, with the assistance of Dr. Doris
Teresita Sy who was also a Resident Physician at the
same Hospital, C.I. and O.R. Nurse Arlene Diones and
some student nurses performed a simple caesarean
section on Mrs. Villegas at the Negros Oriental
Provincial Hospital and after 45 minutes Mrs.
Villegas delivered her first child, Rachel Acogido, at
about 11:45 that morning. Thereafter, Plaintiff
remained confined at the Hospital until September
27, 1988 during which period of confinement she
was regularly visited by Dr. Batiquin. On September
28, 1988 Mrs. Villegas checked out of the Hospital. . .
and on that same day she paid Dr. Batiquin, thru the
latter's secretary, the amount of P1,500.00 as
"professional fee". . . .
Soon after leaving the Hospital Mrs. Villegas
began to suffer abdominal pains and complained of
being feverish. She also gradually lost her appetite,
so she consulted Dr. Batiquin at the latter's polyclinic
who prescribed for her certain medicines which she
had been taking up to December, 1988.
In the meantime, Mrs. Villegas was given a
Medical Certificate by Dr. Batiquin on October 31,
1988. . . certifying to her physical fitness to return to
her work on November 7, 1988. So, on the second
week of November, 1988 Mrs. Villegas returned to
her work at the Rural Bank of Ayungon, Negros
Oriental.
The abdominal pains and fever kept on
recurring and bothered Mrs. Villegas no end despite
the medications administered by Dr. Batiquin. When
the pains became unbearable and she was rapidly
losing weight she consulted Dr. Ma. Salud Kho at the
Holy Child's Hospital in Dumaguete City on January
20, 1989.
The evidence of Plaintiffs show that when
Dr. Ma. Salud Kho examined Mrs. Villegas at the Holy
Child's Hospital on January 20, 1989 she found Mrs.
Villegas to be feverish, pale and was breathing fast.
Upon examination she felt an abdominal mass one
finger below the umbilicus which she suspected to
be either a tumor of the uterus or an ovarian cyst,
either of which could be cancerous. She had an x-ray
taken of Mrs. Villegas' chest, abdomen and kidney.
She also took blood tests of Plaintiff. A blood count
showed that Mrs. Villegas had an infection inside her
abdominal cavity. The results of all those
examinations impelled Dr. Kho to suggest that Mrs.
Villegas submit to another surgery to which the
latter agreed.
When Dr. Kho opened the abdomen of Mrs.
Villegas she found whitish-yellow discharge inside,
an ovarian cyst on each of the left and right ovaries
which gave out pus, dirt and pus behind the uterus,
and a piece of rubber material on the right side of
the uterus embedded on the ovarian cyst, 2 inches
by 3/4 inch in size. This piece of rubber material
which Dr. Kho described as a "foreign body" looked
like a piece of a "rubber glove". . . and which is also
"rubber-drain like". . . . It could have been a torn
section of a surgeon's gloves or could have come
from other sources. And this foreign body was the
cause of the infection of the ovaries and
consequently of all the discomfort suffered by Mrs.
Villegas after her delivery on September 21, 1988.
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The trial court ruled in favor of Dr. Batiquin
dismissing the complaint, while the CA reversed this
decision holding Dr. Batiquin liable.
ISSUE
W/N the CA committed grave abuse of
discretion by resorting to findings of fact not
supported by the evidence on record?
RULING
Ruling of the CA is affirmed
RATIO:
Considering that we have assessed Dr. Kho
to be a credible witness, her positive testimony [that
a piece of rubber was indeed found in private
respondent Villega's abdomen] prevails over the
negative testimony in favor of the petitioners.
As such, the rule of res ipsa loquitur comes
to fore. This Court has had occasion to delve into the
nature and operation of this doctrine:
This doctrine [res ipsa loquitur] is
stated thus: "Where the thing which causes injury is
shown to be under the management of the
defendant, and the accident is such as in the
ordinary course of things does not happen in those
who have the management use proper care, it
affords reasonable evidence, in the absence of an
explanation by the defendant, that the accident
arose from want of care."
The doctrine of res ipsa loquitur as a rule of
evidence is peculiar to the law of negligence which
recognizes that prima facie negligence may be
established without direct proof and furnishes a
substitute for specific proof of negligence. The
doctrine is not a rule of substantive law, but merely
a mode of proof or a mere procedural convenience.
The rule, when applicable to the facts and
circumstances of a particular case, is not intended to
and does not dispense with the requirement of
proof of culpable negligence on the party charged. It
merely determines and regulates what shall be
prima facie evidence thereof and facilitates the
burden of plaintiff of proving a breach of the duty of
due care. The doctrine can be invoked when and
only when, under the circumstances involved, direct
evidence is absent and not readily available.
In the instant case, all the requisites for
recourse to the doctrine are present. First, the entire
proceedings of the caesarean section were under
the exclusive control of Dr. Batiquin. In this light, the
private respondents were bereft of direct evidence
as to the actual culprit or the exact cause of the
foreign object finding its way into private
respondent Villegas's body, which, needless to say,
does not occur unless through the intersection of
negligence. Second, since aside from the caesarean
section, private respondent Villegas underwent no
other operation which could have caused the
offending piece of rubber to appear in her uterus, it
stands to reason that such could only have been a
by-product of the caesarean section performed by
Dr. Batiquin. The petitioners, in this regard, failed to
overcome the presumption of negligence arising
from resort to the doctrine of res ipsa loquitur. Dr.
Batiquin is therefore liable for negligently leaving
behind a piece of rubber in private respondent
Villegas's abdomen and for all the adverse effects
thereof.
6. Lasam v. Ramolete
FACTS
Three months pregnant Editha Ramolete
was brought to the Lorma Medical Center (LMC) in
San Fernando, La Union due to vaginal bleeding.
Upon advice of petitioner relayed 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’s 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 Editha to undergo a Dilatation and
Curettage Procedure (D&C) or "raspa."
Petitioner performed the D&C procedure.
Editha was discharged from the hospital the
following day.
After one month and a half, Editha was
once again brought at the LMC, as she was suffering
from vomiting and severe abdominal pains. Editha
was attended by Dr. Beatriz de la Cruz, Dr. Victor B.
Mayo and Dr. Juan V. Komiya. Dr. Mayo allegedly
informed Editha that there was a dead fetus in the
latter’s womb. After, Editha underwent laparotomy,
she was found to have a massive intra-abdominal
hemorrhage and a ruptured uterus. Thus, Editha had
to undergo a procedure for hysterectomy and as a
result, she has no more chance to bear a child.
Editha and her husband Claro Ramolete
(respondents) filed a Complaint for Gross Negligence
and Malpractice against petitioner before the
Professional Regulations Commission (PRC).
Respondents alleged that Editha’s
hysterectomy was caused by petitioner’s
unmitigated negligence and professional
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incompetence in conducting the D&C procedure and
the petitioner’s failure to remove the fetus inside
Editha’s womb. Among the alleged acts of
negligence were: first, petitioner’s failure to check
up, visit or administer medication on Editha during
her first day of confinement at the LMC; second,
petitioner recommended that a D&C procedure be
performed on Editha without conducting any
internal examination prior to the procedure; third,
petitioner immediately suggested a D&C procedure
instead of closely monitoring the state of pregnancy
of Editha.
The Board of Medicine of PRC exonerated
Dr. Lasam from the charges filed against her. On
appeal to the PRC, the decision of the Board of
Medicine was reversed and the license of Dr. Lasam
was revoked. Dr. Lasam then appealed the decision
of the PRC to the CA under Rule 43.
ISSUE:
1. W/N the petition to the CA was
erroneous, as PRC is not included in the list of the
quasi-judicial agencies whose decision can be
appealed to the CA?
2. W/N an expert witness is needed to
support and establish the medical negligence case
that was filed against Dr.Lasam?
RULING:
Petition is granted. The decision of the
Board of Medicine is reinstated.
RATIO:
1.Indeed, the PRC is not expressly
mentioned as one of the agencies which are
expressly enumerated under Section 1, Rule 43 of
the Rules of Court. However, its absence from the
enumeration does not, by this fact alone, imply its
exclusion from the coverage of said Rule. The Rule
expressly provides that it should be applied to
appeals from awards, judgments final orders or
resolutions of any quasi-judicial agency in the
exercise of its quasi-judicial functions. The phrase
"among these agencies" confirms that the
enumeration made in the Rule is not exclusive to the
agencies therein listed.
Specifically, the Court, in Yang v. Court of Appeals,
ruled that Batas Pambansa (B.P.) Blg. 129 conferred
upon the CA exclusive appellate jurisdiction over
appeals from decisions of the PRC. The Court held:
The law has since been changed, however,
at least in the matter of the particular court
to which appeals from the Commission
should be taken. On August 14, 1981, Batas
Pambansa Bilang 129 became effective and
in its Section 29, conferred on the Court of
Appeals "exclusive appellate jurisdiction
over all final judgments, decisions,
resolutions, orders or awards of Regional
Trial Courts and quasi-judicial agencies,
instrumentalities, boards or commissions
except those falling under the appellate
jurisdiction of the Supreme Court. x x x." In
virtue of BP 129, appeals from the
Professional Regulations Commission are
now exclusively cognizable by the Court of
Appeals.
Clearly, the enactment of B.P. Blg. 129, the
precursor of the present Rules of Civil Procedure,
lodged with the CA such jurisdiction over the appeals
of decisions made by the PRC.
2. 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
causation.
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 is injured in body or in
health, constitutes actionable malpractice. As to this
aspect of medical malpractice, the determination of
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UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
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the reasonable level of care and the breach thereof,
expert testimony is essential. Further, inasmuch 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 support the
conclusion as to causation.
In the present case, respondents did not
present any expert testimony to support their claim
that petitioner failed to do something which a
reasonably prudent physician or surgeon would have
done.
Petitioner, on the other hand, presented
the testimony of Dr. Augusto M. Manalo, who was
clearly an expert on the subject.
Generally, to qualify as an expert witness,
one must have acquired special knowledge of the
subject matter about which he or she is to testify,
either by the study of recognized authorities on the
subject or by practical experience.
Dr. Manalo specializes in gynecology and
obstetrics, authored and co-authored various
publications on the subject, and is a professor at the
University of the Philippines. According to him, his
diagnosis of Editha’s case was "Ectopic Pregnancy
Interstitial (also referred to as Cornual), Ruptured."
In stating that the D&C procedure was not the
proximate cause of the rupture of Editha’s uterus
resulting in her hysterectomy,
From the foregoing testimony, it is clear
that the D&C procedure was conducted in
accordance with the standard practice, with the
same level of care that any reasonably competent
doctor would use to treat a condition under the
same circumstances, and that there was nothing
irregular in the way the petitioner dealt with Editha.
It is undisputed that Editha did not return
for a follow-up evaluation, in defiance of the
petitioner’s advise. Editha omitted the diligence
required by the circumstances which could have
avoided the injury. The omission in not returning for
a follow-up evaluation played a substantial part in
bringing about Editha’s own injury. Had Editha
returned, petitioner could have conducted the
proper medical tests and procedure necessary to
determine Editha’s health condition and applied the
corresponding treatment which could have
prevented the rupture of Editha’s uterus. The D&C
procedure having been conducted in accordance
with the standard medical practice, it is clear that
Editha’s omission was the proximate cause of her
own injury and not merely a contributory negligence
on her part.
Contributory negligence is the act or
omission amounting to want of ordinary care on the
part of the person injured, which, concurring with
the defendant’s negligence, is the proximate cause
of the injury. Difficulty seems to be apprehended in
deciding which acts of the injured party shall be
considered immediate causes of the accident. Where
the immediate cause of an accident resulting in an
injury is the plaintiff’s own act, which contributed to
the principal occurrence as one of its determining
factors, he cannot recover damages for the injury.
Again, based on the evidence presented in the
present case under review, in which no negligence
can be attributed to the petitioner, the immediate
cause of the accident resulting in Editha’s injury
was her own omission when she did not return for
a follow-up check up, in defiance of petitioner’s
orders. The immediate cause of Editha’s injury was
her own act; thus, she cannot recover damages
from the injury.
7. Nogales vs. Capitol Medical Center
FACTS
Pregnant with her fourth child, Corazon
Nogales was under the exclusive prenatal care of Dr.
Estrada beginning on her fourth month of
pregnancy. While Corazon was on her last trimester
of pregnancy, Dr. Estrada noted an increase in her
blood pressure and development of leg edema
indicating preeclampsia, which is a dangerous
complication of pregnancy.
Around midnight of 25 May 1976, Corazon
started to experience mild labor pains prompting
Spouses Nogales to see Dr. Estrada at his home.
After examining Corazon, Dr. Estrada advised her
immediate admission to the Capitol Medical Center.
Corazon was admitted at 2:30 a.m. at the
CMC after the staff nurse noted the written
admission request of Dr. Estrada. Upon Corazon's
admission at the CMC, Rogelio Nogales executed and
signed the "Consent on Admission and Agreement"
and "Admission Agreement." Corazon was then
brought to the labor room of the CMC.
Dr. Uy, who was then a resident physician
of CMC, conducted an internal examination of
Corazon. Dr. Uy then called up Dr. Estrada to notify
him of her findings.
Based on the Doctor's Order Sheet, around
3:00 a.m., Dr. Estrada ordered for 10 mg. of valium
to be administered immediately by intramuscular
injection. Dr. Estrada later ordered the start of
intravenous administration of syntocinon admixed
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UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
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with dextrose, 5%, in lactated Ringers' solution, at
the rate of eight to ten micro-drops per minute.
According to the Nurse's Observation
Notes, Dr. Enriquez, an anesthesiologist at CMC, was
notified at 4:15 a.m. of Corazon's admission.
Subsequently, when asked if he needed the services
of an anesthesiologist, Dr. Estrada refused. Despite
Dr. Estrada's refusal, Dr. Enriquez stayed to observe
Corazon's condition.
At 6:00 a.m., Corazon was transferred to
Delivery Room No. 1 of the CMC. At 6:10 a.m.,
Corazon's bag of water ruptured spontaneously. At
6:12 a.m., Corazon's cervix was fully dilated. At 6:13
a.m., Corazon started to experience convulsions.
At 6:15 a.m., Dr. Estrada ordered the
injection of ten grams of magnesium sulfate.
However, Dr. Villaflor, who was assisting Dr. Estrada,
administered only 2.5 grams of magnesium sulfate.
At 6:22 a.m., Dr. Estrada, assisted by Dr.
Villaflor, applied low forceps to extract Corazon's
baby. In the process, a 1.0 x 2.5 cm. piece of cervical
tissue was allegedly torn. The baby came out in an
apnic, cyanotic, weak and injured condition.
Consequently, the baby had to be intubated and
resuscitated by Dr. Enriquez and Dr. Payumo.
At 6:27 a.m., Corazon began to manifest
moderate vaginal bleeding which rapidly became
profuse. Corazon's blood pressure dropped from
130/80 to 60/40 within five minutes. There was
continuous profuse vaginal bleeding. The assisting
nurse administered hemacel through a gauge 19
needle as a side drip to the ongoing intravenous
injection of dextrose.
At 7:45 a.m., Dr. Estrada ordered blood
typing and cross matching with bottled blood. It took
approximately 30 minutes for the CMC laboratory,
headed by Dr. Lacson, to comply with Dr. Estrada's
order and deliver the blood.
At 8:00 a.m., Dr. Espinola, head of the
Obstetrics-Gynecology Department of the CMC, was
apprised of Corazon's condition by telephone. Upon
being informed that Corazon was bleeding profusely,
Dr. Espinola ordered immediate hysterectomy.
Rogelio was made to sign a "Consent to Operation."
Due to the inclement weather then, Dr.
Espinola, who was fetched from his residence by an
ambulance, arrived at the CMC about an hour later
or at 9:00 a.m. He examined the patient and ordered
some resuscitative measures to be administered.
Despite Dr. Espinola's efforts, Corazon died at 9:15
a.m. The cause of death was "hemorrhage, post
partum."
Petitioners filed a complaint for damages
with the RTC against all the doctors including Capitol
Medical Center. The Trial court ruled that Dr. Estrada
was the one solely liable. The petitioners (Nogales)
appealed the decision of the RTC, contending that all
the physicians should be equally liable for
negligence. The CA affirmed the decision of the RTC.
Hence this petition.
ISSUE:
W/N CMC is vicariously liable for the
negligence of Dr. Estrada?
HELD:
Petition partly granted. CMC is held
vicariously liable with Dr. Estrada.
RATIO:
In general, a hospital is not liable for the
negligence of an independent contractor-physician.
There is, however, an exception to this principle. The
hospital may be liable if the physician is the
"ostensible" agent of the hospital. This exception is
also known as the "doctrine of apparent authority."
In Gilbert v. Sycamore Municipal Hospital, the Illinois
Supreme Court explained the doctrine of apparent
authority in this wise:
[U]nder the doctrine of apparent authority
a hospital can be held vicariously liable for
the negligent acts of a physician providing
care at the hospital, regardless of whether
the physician is an independent contractor,
unless the patient knows, or should have
known, that the physician is an
independent contractor. The elements of
the action have been set out as follows:
"For a hospital to be liable under the
doctrine of apparent authority, a plaintiff
must show that: (1) the hospital, or its
agent, acted in a manner that would lead a
reasonable person to conclude that the
individual who was alleged to be negligent
was an employee or agent of the hospital;
(2) where the acts of the agent create the
appearance of authority, the plaintiff must
also prove that the hospital had knowledge
of and acquiesced in them; and (3) the
plaintiff acted in reliance upon the conduct
of the hospital or its agent, consistent with
ordinary care and prudence."
The element of "holding out" on the part of
the hospital does not require an express
representation by the hospital that the
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UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
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person alleged to be negligent is an
employee. Rather, the element is satisfied if
the hospital holds itself out as a provider of
emergency room care without informing
the patient that the care is provided by
independent contractors.
The element of justifiable reliance on the
part of the plaintiff is satisfied if the plaintiff
relies upon the hospital to provide
complete emergency room care, rather
than upon a specific physician.
The doctrine of apparent authority
essentially involves two factors to determine the
liability of an independent-contractor physician.
The first factor focuses on the hospital's
manifestations and is sometimes described as an
inquiry whether the hospital acted in a manner
which would lead a reasonable person to conclude
that the individual who was alleged to be negligent
was an employee or agent of the hospital. In this
regard, the hospital need not make express
representations to the patient that the treating
physician is an employee of the hospital; rather a
representation may be general and implied.
The doctrine of apparent authority is a
species of the doctrine of estoppel. Article 1431 of
the Civil Code provides that "[t]hrough estoppel, an
admission or representation is rendered conclusive
upon the person making it, and cannot be denied or
disproved as against the person relying thereon."
Estoppel rests on this rule: "Whenever a party has,
by his own declaration, act, or omission,
intentionally and deliberately led another to believe
a particular thing true, and to act upon such belief,
he cannot, in any litigation arising out of such
declaration, act or omission, be permitted to falsify
it."
In the instant case, CMC impliedly held out
Dr. Estrada as a member of its medical staff. Through
CMC's acts, CMC clothed Dr. Estrada with apparent
authority thereby leading the Spouses Nogales to
believe that Dr. Estrada was an employee or agent of
CMC. CMC cannot now repudiate such authority.
8. Garcia-Rueda vs. Pascasio
FACTS:
Florencio V. Rueda, husband of petitioner
Leonila Garcia-Rueda, underwent surgical operation
at the UST hospital for the removal of a stone
blocking his ureter. He was attended by Dr. Domingo
Antonio, Jr. who was the surgeon, while Dr. Erlinda
Balatbat-Reyes was the anaesthesiologist. Six hours
after the surgery, however, Florencio died of
complications of "unknown cause," according to
officials of the UST Hospital.
Not satisfied with the findings of the
hospital, petitioner requested the National Bureau
of Investigation (NBI) to conduct an autopsy on her
husband's body. Consequently, the NBI ruled that
Florencio's death was due to lack of care by the
attending physician in administering anaesthesia.
Pursuant to its findings, the NBI recommended that
Dr. Domingo Antonio and Dr. Erlinda Balatbat-Reyes
be charged for Homicide through Reckless
Imprudence before the Office of the City Prosecutor.
(Here comes the Ping-Pong Match which
included 9 prosecutors.)
After the Ping-Pong, the City Prosecutor
exonerated the doctors from any wrongdoing.
Leonila was so badtrip she decided to file Graft
charges against all the prosecutors who took part in
the Ping-Pong match. The Ombudsman dismissed
the complaint for lack of evidence. So, because
Leonila was badtrip again, she filed a petition in the
SC under Rule 65.
ISSUE:
May the SC review the findings of the
Ombudsman?
HELD:
They do not have the GALACTIC POWER.
RATIO:
The general rule has been enunciated in
Ocampo v. Ombudsman which states:
In the exercise of its investigative
power, this Court has consistently
held that courts will not interfere
with the discretion of the fiscal or
the Ombudsman to determine the
specificity and adequacy of the
averments of the offense charged.
He may dismiss the complaint
forthwith if he finds it to be
insufficient in form and substance
or if he otherwise finds no ground
to continue with the inquiry; or he
may proceed with the investigation
of the complaint if, in his view, it is
in due and proper form.
To our mind, the better and more logical remedy
under the circumstances would have been to appeal
the resolution of the City Prosecutors dismissing the
criminal complaint to the Secretary of Justice under
the Department of Justice's Order No. 223,
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UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
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otherwise known as the "1993 Revised Rules on
Appeals From Resolutions In Preliminary
Investigations/Reinvestigations," as amended by
Department Order No. 359, Section 1 of which
provides:
Sec. 1. What May Be Appealed. —
Only resolutions of the Chief State
Prosecutor/Regional State
Prosecutor/Provincial or City
Prosecutor dismissing a criminal
complaint may be the subject of an
appeal to the Secretary of Justice
except as otherwise provided in
Section 4 hereof.
What action may the Secretary of Justice take on the
appeal? Section 9 of Order No. 223 states: "The
Secretary of Justice may reverse, affirm or modify
the appealed resolution." On the other hand, "He
may motu proprio or on motion of the appellee,
dismiss outright the appeal on specified grounds."
In exercising his discretion under the circumstances,
the Ombudsman acted within his power and
authority in dismissing the complaint against the
Prosecutors and this Court will not interfere with the
same.
9. Professional Services Inc. vs. Agana
FACTS
On April 4, 1984, Natividad Agana was
rushed to the Medical City General Hospital because
of difficulty of bowel movement and bloody anal
discharge. After a series of medical examinations, Dr.
Miguel Ampil, petitioner in G.R. No. 127590,
diagnosed her to be suffering from "cancer of the
sigmoid."
On April 11, 1984, Dr. Ampil, assisted by the
medical staff of the Medical City Hospital, performed
an anterior resection surgery on Natividad. He found
that the malignancy in her sigmoid area had spread
on her left ovary, necessitating the removal of
certain portions of it. Thus, Dr. Ampil obtained the
consent of Natividad’s husband, Enrique Agana, to
permit Dr. Juan Fuentes, respondent in G.R. No.
126467, to perform hysterectomy on her.
After Dr. Fuentes had completed the
hysterectomy, Dr. Ampil took over, completed the
operation and closed the incision.
However, the operation appeared to be
flawed. In the corresponding Record of Operation
dated April 11, 1984, the attending nurses entered
these remarks:
"sponge count lacking 2
"announced to surgeon searched (sic) done but to
no avail continue for closure."
On April 24, 1984, Natividad was released
from the hospital. Her hospital and medical bills,
including the doctors’ fees, amounted to P60,000.00.
After a couple of days, Natividad
complained of excruciating pain in her anal region.
She consulted both Dr. Ampil and Dr. Fuentes about
it. They told her that the pain was the natural
consequence of the surgery. Dr. Ampil then
recommended that she consult an oncologist to
examine the cancerous nodes which were not
removed during the operation.
On May 9, 1984, Natividad, accompanied by
her husband, went to the United States to seek
further treatment. After four months of
consultations and laboratory examinations,
Natividad was told she was free of cancer. Hence,
she was advised to return to the Philippines.
On August 31, 1984, Natividad flew back to
the Philippines, still suffering from pains. Two weeks
thereafter, her daughter found a piece of gauze
protruding from her vagina. Upon being informed
about it, Dr. Ampil proceeded to her house where he
managed to extract by hand a piece of gauze
measuring 1.5 inches in width. He then assured her
that the pains would soon vanish.
Dr. Ampil’s assurance did not come true.
Instead, the pains intensified, prompting Natividad
to seek treatment at the Polymedic General
Hospital. While confined there, Dr. Ramon Gutierrez
detected the presence of another foreign object in
her vagina -- a foul-smelling gauze measuring 1.5
inches in width which badly infected her vaginal
vault. A recto-vaginal fistula had formed in her
reproductive organs which forced stool to excrete
through the vagina. Another surgical operation was
needed to remedy the damage. Thus, in October
1984, Natividad underwent another surgery.
On November 12, 1984, Natividad and her
husband filed with the RTC a complaint for damages
against the Professional Services, Inc. (PSI), owner of
the Medical City Hospital, Dr. Ampil, and Dr.
Fuentes. They alleged that the latter are liable for
negligence for leaving two pieces of gauze inside
Natividad’s body and malpractice for concealing
their acts of negligence.
Meanwhile, Enrique Agana also filed with
the Professional Regulation Commission (PRC) an
administrative complaint for gross negligence and
malpractice against Dr. Ampil and Dr. Fuentes.
The RTC rendered its Decision in favor of
the Aganas, finding PSI, Dr. Ampil and Dr. Fuentes
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UNIVERSALLY GALACTIC NOTES IN LEGAL MEDICINE/LOGRONIO-ISMS
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liable for negligence and malpractice. Aggrieved, PSI,
Dr. Fuentes and Dr. Ampil interposed an appeal to
the Court of Appeals. The CA ruled that only Dr.
Ampil should be held liable and he should reimburse
PSI for whatever the latter had paid or is going to
pay the Aganas.
ISSUE:
1. W/N the CA erred in ruling that only Dr.
Ampil is liable.
2. W/N PSI as owner of the Hospital should
also be held liable.
HELD:
Petition Denied. Professional Services, Inc.
is ORDERED pro hac vice to pay and Enrique Agana
the total amount of P15 million, subject to 12% p.a.
interest from the finality of this resolution to full
satisfaction.
RATIO:
After gathering its thoughts on the issues,
this Court holds that PSI is liable to the Aganas, not
under the principle of respondeat superior for lack of
evidence of an employment relationship with Dr.
Ampil but under the principle of ostensible agency
for the negligence of Dr. Ampil and, pro hac vice,
under the principle of corporate negligence for its
failure to perform its duties as a hospital.
While in theory a hospital as a juridical
entity cannot practice medicine, in reality it utilizes
doctors, surgeons and medical practitioners in the
conduct of its business of facilitating medical and
surgical treatment. Within that reality, three legal
relationships crisscross: (1) between the hospital and
the doctor practicing within its premises; (2)
between the hospital and the patient being treated
or examined within its premises and (3) between the
patient and the doctor. The exact nature of each
relationship determines the basis and extent of the
liability of the hospital for the negligence of the
doctor.
Where an employment relationship exists,
the hospital may be held vicariously liable under
Article 2176 in relation to Article 2180 of the Civil
Code or the principle of respondeat superior. Even
when no employment relationship exists but it is
shown that the hospital holds out to the patient that
the doctor is its agent, the hospital may still be
vicariously liable under Article 2176 in relation to
Article 1431 and Article 1869 of the Civil Code or the
principle of apparent authority. Moreover,
regardless of its relationship with the doctor, the
hospital may be held directly liable to the patient for
its own negligence or failure to follow established
standard of conduct to which it should conform as a
corporation.
Nonetheless, to allay the anxiety of the
intervenors, the Court holds that, in this particular
instance, the concurrent finding of the RTC and the
CA that PSI was not the employer of Dr. Ampil is
correct. Control as a determinative factor in testing
the employer-employee relationship between doctor
and hospital under which the hospital could be held
vicariously liable to a patient in medical negligence
cases is a requisite fact to be established by
preponderance of evidence. Here, there was
insufficient evidence that PSI exercised the power of
control or wielded such power over the means and
the details of the specific process by which Dr. Ampil
applied his skills in the treatment of Natividad.
Consequently, PSI cannot be held vicariously liable
for the negligence of Dr. Ampil under the principle of
respondeat superior.
There is, however, ample evidence that the
hospital (PSI) held out to the patient (Natividad) that
the doctor (Dr. Ampil) was its agent. Present are the
two factors that determine apparent authority: first,
the hospital's implied manifestation to the patient
which led the latter to conclude that the doctor was
the hospital's agent; and second, the patient’s
reliance upon the conduct of the hospital and the
doctor, consistent with ordinary care and prudence.
To begin with, PSI could not simply wave off
the problem and nonchalantly delegate to Dr. Ampil
the duty to review what transpired during the
operation. The purpose of such review would have
been to pinpoint when, how and by whom two
surgical gauzes were mislaid so that necessary
remedial measures could be taken to avert any
jeopardy to Natividad’s recovery. Certainly, PSI could
not have expected that purpose to be achieved by
merely hoping that the person likely to have mislaid
the gauzes might be able to retrace his own steps. By
its own standard of corporate conduct, PSI's duty to
initiate the review was non-delegable.
While Dr. Ampil may have had the primary
responsibility of notifying Natividad about the
missing gauzes, PSI imposed upon itself the separate
and independent responsibility of initiating the
inquiry into the missing gauzes. The purpose of the
first would have been to apprise Natividad of what
transpired during her surgery, while the purpose of
the second would have been to pinpoint any lapse in
procedure that led to the gauze count discrepancy,
so as to prevent a recurrence thereof and to
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determine corrective measures that would ensure hemmed and hawed at every turn, disowning any
the safety of Natividad. That Dr. Ampil negligently such responsibility to its patient. Meanwhile, the
failed to notify Natividad did not release PSI from its options left to the Aganas have all but dwindled, for
self-imposed separate responsibility. the status of Dr. Ampil can no longer be ascertained.
Corollary to its non-delegable undertaking
to review potential incidents of negligence Disclaimer: Guys, sensha na… I cannot go on… last
committed within its premises, PSI had the duty to case na lang naman… Kayo na bahala… hehehe…
take notice of medical records prepared by its own GOD BLESS US!!! ;)
staff and submitted to its custody, especially when
these bear earmarks of a surgery gone awry. Thus,
the record taken during the operation of Natividad
which reported a gauze count discrepancy should
have given PSI sufficient reason to initiate a review.
It should not have waited for Natividad to complain.
As it happened, PSI took no heed of the
record of operation and consequently did not initiate
a review of what transpired during Natividad’s
operation. Rather, it shirked its responsibility and
passed it on to others – to Dr. Ampil whom it
expected to inform Natividad, and to Natividad
herself to complain before it took any meaningful
step. By its inaction, therefore, PSI failed its own
standard of hospital care. It committed corporate
negligence.
It should be borne in mind that the
corporate negligence ascribed to PSI is different
from the medical negligence attributed to Dr. Ampil.
The duties of the hospital are distinct from those of
the doctor-consultant practicing within its premises
in relation to the patient; hence, the failure of PSI to
fulfill its duties as a hospital corporation gave rise to
a direct liability to the Aganas distinct from that of
Dr. Ampil.
All this notwithstanding, we make it clear
that PSI’s hospital liability based on ostensible
agency and corporate negligence applies only to this
case, pro hac vice. It is not intended to set a
precedent and should not serve as a basis to hold
hospitals liable for every form of negligence of their
doctors-consultants under any and all circumstances.
The ruling is unique to this case, for the liability of
PSI arose from an implied agency with Dr. Ampil and
an admitted corporate duty to Natividad.
Other circumstances peculiar to this case
warrant this ruling, not the least of which being that
the agony wrought upon the Aganas has gone on for
26 long years, with Natividad coming to the end of
her days racked in pain and agony. Such
wretchedness could have been avoided had PSI
simply done what was logical: heed the report of a
guaze count discrepancy, initiate a review of what
went wrong and take corrective measures to ensure
the safety of Nativad. Rather, for 26 years, PSI

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Injuries Dead Body

Stab wound – caused by a knife; sharp/pointed edge *to document death in a hospital setting, ECG (flat
Puncture wound – caused by an icepick; pointed line) is always performed
object
Hack wound – caused by a “bolo” or “itak” Changes:
1. TEMPERATURE
INCISED WOUND LACERATED WOUND *will remain almost the same until about 3
Linear injury Not straight edge, hair hours after death when the body temp will
bulbs not removed start to drop
Clean cut Razed skin
Caused by a sharp edge Boxing match; hit by a 2. MUSCLES
ex. cutter bolo *flaccid
*after 3 hours, it will start to stiffen (Rigor
Gunshot wound- may be caused by bullet; there is Mortis)
an entry and an exit wound *12 hours after death galactic Rigor Mortis
*even number of gunshot wounds would *24-36 hours after death, flaccid again
give the presumption that there are no more bullets
left inside the body 3. BLOOD
*will go to the most dependent part of the
*odd number of gunshot wounds would
give rise to the presumption that there are still body
bullets left inside the body *post mortem lividity (blood will go down)
*points of entry are important because it *depends on the position of the body when
person died
will tell the distance and position of the assailant
*will start 3 hours after death
*if shot in close range, will leave marks on
the body SUICIDE V. HOMICIDE
-hair will be burned if shot 3 inches away  notes/ letters stating reasons therefor
-there will be smoke smudges if shot 6  taking up Civil Procedure
inches away  stiffening of the muscles in the hand
-there will be unburned gunpowder if shot  traumatic breath –cadaveric spasm;
12 inches away extreme tension at time of death

*presence of abrasion marks/abrasion collar means *if suicide, patient dies immediately, cadaveric
that the bullet rubbed the skin first before entering spasm in hand/arm; hand firmly clenched
the body, hence, victim was not shot in front *if drowned, hands are firmly clenched also
NOTE: NO Abrasion Collar = Frontal(?) Shot

Hematoma – pasa THROAT SLASHING

Abrasion – gasgas  homicide = below adam’s apple (also in
Contusion – bukol hanging)
 cut is diagonal in suicide (how the fuck
In rape, there are usually hymenal lacerations which can a person slit his own throat
are distinguished and determined by using the face vertically?)
of the clock
*there are usually multiple hymenal lacerations in
rape
*hematoma on legs/perineum area

Burns (Explosives) – measured by percentage

*1 hand = 1 percent

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