Medical Malpractice Cases (PDF)

Based on the lectures of Atty. Francis Talon, RN, MD ㎡ MEDICAL MALPRACTICE Garcia-Rueda vs. Pascasio [ G.R. No. 118141. September 05, 1997 ] FACTS: Florencio Rueda underwent surge...

Based on the lectures of Atty. Francis Talon, RN, MD ㎡ MEDICAL MALPRACTICE Garcia-Rueda vs. Pascasio [ G.R. No. 118141. September 05, 1997 ] FACTS: Florencio Rueda underwent surgery for removal of stone blocking his ureter at the UST hospital. The attendings were Dr. Antonio (surgeon) and Dr. Balatbat-Reyes (anesthesiologist). Six hours after surgery, he died of unknown complications. Garcia-Rueda (H) requested the NBI to conduct an autopsy. NBI found that the death was caused by lack of care in administering anesthesia, and recommended that the attending physicians be charged with homicide through reckless imprudence. RULING: BOTH doctors are HELD LIABLE. It appears there was negligence in administering the anesthesia and that the cause of death could have been prevented if the proper drug was administered to cope with the symptoms of malignant hyperthermia. There are four elements involved in medical negligence cases: duty, breach, injury and proximate causation. D-B-I-P 1) DUTY - when the victim employed the services of Dr. Antonio and Dr. Reyes, a physician- patient relationship was created. They have a duty to use at least the same level of care that any other reasonably competent doctor would use to treat a condition under the same circumstances. 2) BREACH - 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. 3) INJURY - in the event that any injury results to the patient from want of due care or skill during the operation, the surgeons may be held answerable in damages for negligence. 4) PROXIMATE CAUSATION - another element in medical negligence cases is causation which is divided into two inquiries: whether the doctor’s actions in fact caused the harm to the patient and whether these were the proximate cause of the patient’s injury. Indeed here, a causal connection is discernible from the occurrence of the victim’s death after the negligent act of the anaesthesiologist in administering the anesthesia, a fact which, if confirmed, should warrant the filing of the appropriate criminal case. To be sure, the allegation of negligence is not entirely baseless. Moreover, the NBI deduced that the attending surgeons did not conduct the necessary interview of the patient prior to the operation. It appears that the cause of the death of the victim could have been averted had the proper drug been applied to cope with the symptoms of malignant hyperthermia. In malpractice or negligence cases involving the administration of anaesthesia, the necessity of expert testimony and the availability of the charge of res ipsa loquitur to the plaintiff, have been applied in actions against anaesthesiologists to hold the defendant liable for the death or injury of a patient under excessive or improper anaesthesia. Essentially, it requires two-pronged evidence: evidence as to the recognized standards of the medical community in the particular kind of case, and a showing that the physician in question negligently departed from this standard in his treatment. Cruz vs. CA [ G.R. No. 122445. November 18, 1997 ] FACTS: Rowena’s mother, Lydia, had myoma in her uterus and was scheduled for a hystererectomy operation. Rowena and Lydia slept in the clinic to await the operation the next. Day. Rowena noticed that the clinic was untidy and dusty, she convinced Lydia to transfer hospital. The operation proceeded and during which Rowena was tasked by Dr. Ercillo to get additional blood packs to which she immediately procured. After the operation, additional blood and oxygen tank were required. The procurement of the oxygen tank was too late and Rowena’s mother was put into “shock”. Lydia had to be transferred to a better hospital, and was done so without notice and consent to Rowena. When Lydia was wheeled into the operating room of San Pablo District Hospital, Dr. Angeles arrived upon call and saw that Lydia has blood coming out from her abdominal incision and saw that she was in shock and that her blood pressure was already at 0/0. Dr. Angeles informed Dr. Ercillo and Rowena 1 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ that there’s nothing that they can do. RULING: Insufficient to sustain a judgment of conviction against the petitioner for the crime of reckless imprudence resulting in homicide. 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. 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. Immediately apparent from a review of the records of this case is the absence of any expert testimony on the matter of the standard of care employed by other physicians of good standing in the conduct of similar operations. The prosecution's expert witnesses in the persons of Dr. Floresto Arizala and Dr. Nieto Salvador, Jr. of the National Bureau of Investigation (NBI) only testified as to the possible cause of death but did not venture to illuminate the court on the matter of the standard of care that petitioner should have exercised. All three courts below bewail the inadequacy of the facilities of the clinic and its untidiness; the lack of provisions such as blood, oxygen, and certain medicines; the failure to subject the patient to a cardio- pulmonary test prior to the operation; the omission of any form of blood typing before transfusion; and even the subsequent transfer of Lydia to the San Pablo Hospital and the reoperation performed on her by the petitioner. But while it may be true that the circumstances pointed out by the courts below seemed beyond cavil to constitute reckless imprudence on the part of the surgeon, this conclusion is still best arrived at not through the educated surmises nor conjectures of laymen, including judges, but by the unquestionable knowledge of expert witnesses. For whether a physician or surgeon has exercised the requisite degree of skill and care in the treatment of his patient is, in the generality of cases, a matter of expert opinion. Expert testimony should have been offered to prove that the circumstances cited by the courts below are constitutive of conduct falling below the standard of care employed by other physicians in good standing when performing the same operation. It must be remembered that when the qualifications of a physician are admitted, as in the instant case, there is an inevitable presumption that in proper cases he takes the necessary precaution and employs the best of his knowledge and skill in attending to his clients, unless the contrary is sufficiently established. This presumption is rebuttable by expert opinion which is so sadly lacking in the case at bench. Even granting arguendo that the inadequacy of the facilities and untidiness of the clinic; the lack of provisions; the failure to conduct pre-operation tests on the patient; and the subsequent transfer of Lydia to the San Pablo Hospital and the reoperation performed on her by the petitioner do indicate, even without expert testimony, that petitioner was recklessly imprudent in the exercise of her duties as a surgeon, no cogent proof exists that any of these circumstances caused petitioner's death. Thus, the absence of the fourth element of reckless imprudence: that the injury to the person or property was a consequence of the reckless imprudence. Ramos vs. CA [ G.R. No. 124354. December 29, 1999 ] FACTS: Erlina Ramosa underwent a surgical procedure to remove stone from her gall bladder (cholecystectomy). They hired Dr. Hosaka, a surgeon, to conduct the surgery at the De Los Santos Medical Center. The operation did not go as planned, Dr. Hosaka arrived 3 hours late for the operation. Dra. Gutierrez, anesthesiologist, “botched” the administration of the anesthesia causing Erlina to go into a coma and suffer brain damage. The botched operation was witnessed by Herminda Cruz (sis-in-law). 2 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ RULING: “Res ipsa loquitur” - not a rule of substantive law BUT a mode of proof. Hence, in cases where the res ipsa loquitur is applicable, the court is permitted to find a physician negligent upon proper proof of injury to the patient, without the aid of expert testimony, where the court from its fund of common knowledge can determine the proper standard of care. 30 Where common knowledge and experience teach that a resulting injury would not have occurred to the patient if due care had been exercised, an inference of negligence may be drawn giving rise to an application of the doctrine of res ipsa loquitur without medical evidence, which is ordinarily required to show not only what occurred but how and why it occurred. When the doctrine is appropriate, all that the patient must do is prove a nexus between the particular act or omission complained of and the injury sustained while under the custody and management of the defendant without need to produce expert medical testimony to establish the standard of care. Resort to res ipsa loquitur is allowed because there is no other way, under usual and ordinary conditions, by which the patient can obtain redress for injury suffered by him. EFFECT OF RIL 1) Raise a presumption of negligence 2) Becomes a question of fact on the part of the defendant to prove Elements of RIL (1) Occurrence of an injury; (2) The thing which caused the injury was under the control and management of the defendant; (3) The occurrence was such that in the ordinary course of things, would not have happened if those who had control or management used proper care; and (4) The absence of explanation by the defendant. Of the foregoing requisites, the most instrumental is the control and management of the thing which caused the injury. 1) Incident must be unusual and extraordinary (not common) 2) Control of the instrumentality - medical professional must have control over his paraphernalia 3) Absence of contributory negligence of the patient Qualification as an Expert Witness 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. Clearly, Dr. Jamora does not qualify as an expert witness based on the above standard since he lacks the necessary knowledge, skill, and training in the field of anesthesiology. Oddly, apart from submitting testimony from a specialist in the wrong field, private respondents' intentionally avoided providing testimony by competent and independent experts in the proper areas. Proximate cause has been defined as that which, in natural and continuous sequence, unbroken by any efficient intervening cause, produces injury, and without which the result would not have occurred. The doctors and the hospital are made liable. Reyes vs. Sisters of Mercy Hospital [ G.R. No. 130547. October 03, 2000 ] FACTS: Five days before Jorge’s death, Jorge has been suffering from recurring fever with chills. The doctors confirmed through the Widal Test that Jorge has typhoid fever. However, he did not respond to the treatment and died. The cause of his death was “Ventricular Arrythemia Secondary to Hyperpyrexia and typhoid fever.” The contention was that he died due to the wrongful administration of chloromycetin. RULING: There are thus four elements involved in medical negligence cases, namely: duty, breach, injury, and proximate causation. In the present case, there is no doubt that a physician-patient relationship existed between respondent doctors and Jorge Reyes. Respondents were thus duty-bound to use at least the same level of care that 3 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ any reasonably competent doctor would use to treat a condition under the same circumstances. It is breach of this duty which constitutes actionable malpractice. As to this aspect of medical malpractice, the determination of the reasonable level of care and the breach thereof, expert testimony is essential. 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. Res ipsa loquitur Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied, depending upon the circumstances of each case. It is generally restricted to situations in malpractice cases where a layman is able to say, as a matter of common knowledge and observation, that the consequences of professional care were not as such as would ordinarily have followed if due care had been exercised. A distinction must be made between the failure to secure results, and the occurrence of something more unusual and not ordinarily found if the service or treatment rendered followed the usual procedure of those skilled in that particular practice. It must be conceded that the doctrine of res ipsa loquitur can have no application in a suit against a physician or a surgeon which involves the merits of a diagnosis or of a scientific treatment. The physician or surgeon is not required at his peril to explain why any particular diagnosis was not correct, or why any particular scientific treatment did not produce the desired result. In this case, while it is true that the patient died just a few hours after professional medical assistance was rendered, there is really nothing unusual or extraordinary about his death. Prior to his admission, the patient already had recurring fevers and chills for five days unrelieved by the analgesic, antipyretic, and antibiotics given him by his wife. This shows that he had been suffering from a serious illness and professional medical help came too late for him. Ramos vs. CA [ G.R. No. 124354. April 11, 2002 ] Motion for Reconsideration FACTS: Contention - No EE-ER relationship. Doctor is paid by patient NOT the hospital. RULING: There is no employer-employee relationship between DLSMC and Drs. Gutierrez and Hosaka which would hold DLSMC solidarily liable for the injury suffered by petitioner Erlinda under Article 2180 of the Civil Code. Moreover, the contract between the consultant in respondent hospital and his patient is separate and distinct from the contract between respondent hospital and said patient. (hospital has NO LIABILITY) HOSPITAL LIABILITY Hospital and Doctore are LIABLE (because of its vicarious relationship). Captain of the Ship Doctrine Under this doctrine, a surgeon is likened to a captain of the ship, in that it is his duty to control everything going on in the operating room. Dr. Hosaka: The Doctrine is rejected based on US trend. SC: That there is a trend in American jurisprudence to do away with the Captain-of-the-Ship doctrine does not mean that this Court will ipso facto follow said trend. (Dr. Hosaka is still liable under the Captain of the Ship Doctrine) 4 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ Nogales vs. Capitol Medical Center [ G.R. NO. 142625. December 19, 2006 ] FACTS: Dr. Estrada noted an increase in her blood pressure and development of leg edema indicating preeclampsia, which is a dangerous complication of pregnancy. Corzaon Nogales started to experience mild labor pains prompting them to see Dr. Estrada at his home. Then, they were advised to be admitted to the Capitol Medical Center (CMC). There was continuous profuse vaginal bleeding. Dr. Espinola (OB), arrived at the CMC about an hour later. He examined the patient and ordered some resuscitative measures to be administered but Corazon eventually died. RULING: Dr. Estrada is an independent contractor After a thorough examination of the voluminous records of this case, the Court finds no single evidence pointing to CMC's exercise of control over Dr. Estrada's treatment and management of Corazon's condition. It is undisputed that throughout Corazon's pregnancy, she was under the exclusive prenatal care of Dr. Estrada. At the time of Corazon's admission at CMC and during her delivery, it was Dr. Estrada, assisted by Dr. Villaflor, who attended to Corazon. There was no showing that CMC had a part in diagnosing Corazon's condition. While Dr. Estrada enjoyed staff privileges at CMC, such fact alone did not make him an employee of CMC.42 CMC merely allowed Dr. Estrada to use its facilities43 when Corazon was about to give birth, which CMC considered an emergency. Considering these circumstances, Dr. Estrada is not an employee of CMC, but an independent contractor. GR: a hospital is not liable for the negligence of an independent contractor-physician EXC: Under 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. Elements: (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 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. i) hospital manifestations - 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. ii) patient’s reliance - sometimes characterized as an inquiry on whether the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with ordinary care and prudence. Doctrine of Apparent Authority is applicable. Not as an employee, but because of the two factors → AGENT 5 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ Cantre vs. Spouses Go [ G.R. No. 160889. April 27, 2007 ] FACTS: Nora gave birth to her fourth child, a baby boy. However, at around 3:30 a.m., 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 sustained a wound on her left arm from the droplight. RULING: RES IPSA LOQUITUR 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. Professional Services Inc. vs. Agana [ G.R. NO. 126297. January 31, 2007 ] FACTS: Natividad Agana was diagnosed with cancer of the sigmoid which also affected her ovaries. She underwent surgical operations to remove the cancer. However, after receiving treatments and being declared free of cancer, she still felt excruciating pains in her rectal and vaginal area. It turns out that the pains were caused by the pieces of gauze left inside her body. Dr. Ampil - lead surgeon RULING: Elements of Medical Malpractice 1) DUTY - Dr. Ampil, as the lead surgeon, had the duty to remove all foreign objects, such as gauzes, from Natividad’s body before closure of the incision. 2) BREACH OF DUTY - When he failed to do so, it was his duty to inform Natividad about it. Dr. Ampil breached both duties. 6 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ 3) CAUSE OF INJURY - Such breach caused injury to Natividad, necessitating her further examination by American doctors and another surgery. 4) PROXIMATE CAUSATION - That Dr. Ampil’s negligence is the proximate cause of Natividad’s injury could be traced from his act of closing the incision despite the information given by the attending nurses that two pieces of gauze were still missing. That they were later on extracted from Natividad’s vagina established the causal link between Dr. Ampil’s negligence and the injury. And what further aggravated such injury was his deliberate concealment of the missing gauzes from the knowledge of Natividad and her family. Doctrine of Res Ipsa Loquitur - REQUISITES (4) (1) the occurrence of an injury; (2) the thing which caused the injury was under the control and management of the defendant; (3) the occurrence was such that in the ordinary course of things, would not have happened if those who had control or management used proper care; and (4) the absence of explanation by the defendant. Of the foregoing requisites, the most instrumental is the "control and management of the thing which caused the injury." →Absence of element of "control and management of the thing which caused the injury" It was duly established that Dr. Ampil was the lead surgeon during the operation of Natividad. He requested the assistance of Dr. Fuentes only to perform hysterectomy when he (Dr. Ampil) found that the malignancy in her sigmoid area had spread to her left ovary. Dr. Fuentes performed the surgery and thereafter reported and showed his work to Dr. Ampil. The latter examined it and finding everything to be in order, allowed Dr. Fuentes to leave the operating room. Dr. Ampil then resumed operating on Natividad. He was about to finish the procedure when the attending nurses informed him that two pieces of gauze were missing. A "diligent search" was conducted, but the misplaced gauzes were not found. Dr. Ampil then directed that the incision be closed. During this entire period, Dr. Fuentes was no longer in the operating room and had, in fact, left the hospital. Under the "Captain of the Ship" rule, the operating surgeon is the person in complete charge of the surgery room and all personnel connected with the operation. Their duty is to obey his orders.16 As stated before, Dr. Ampil was the lead surgeon. In other words, he was the "Captain of the Ship." That he discharged such role is evident from his following conduct: (1) calling Dr. Fuentes to perform a hysterectomy; (2) examining the work of Dr. Fuentes and finding it in order; (3) granting Dr. Fuentes’ permission to leave; and (4) ordering the closure of the incision. To our mind, it was this act of ordering the closure of the incision notwithstanding that two pieces of gauze remained unaccounted for, that caused injury to Natividad’s body. Clearly, the control and management of the thing which caused the injury was in the hands of Dr. Ampil, not Dr. Fuentes. GR: foreign object left → always negligence per se. EXC: danger to patient’s life → surgeon’s legal duty to so inform his patient within a reasonable time thereafter by advising her of what he had been compelled to do EE-ER relationship ✔ Regardless of the education and status in life of the patient, he ought not be burdened with the defense of absence of employer-employee relationship between the hospital and the independent physician whose name and competence are certainly certified to the general public by the hospital’s act of listing him and his specialty in its lobby directory, as in the case herein. Doctrine of Corporate Negligence PSI is directly liable for such breach of duty. It was duly established that PSI operates the Medical City Hospital for the purpose and under the concept of providing comprehensive medical services to the public. Accordingly, it has the duty to exercise reasonable care to protect from harm all patients admitted into its facility for medical treatment. Unfortunately, PSI failed to perform such duty. 7 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ Professional Services Inc. vs. CA and Agana [ G.R. No. 126297. February 11, 2008 ] Motion for Reconsideration FACTS: PSI contended that they should not be held liable for the negligence of physicians-consultants allowed to practice in its premises. RULING: PSI cannot be liable under doctrine of corporate negligence since the proximate cause of Mrs. Agana's injury was the negligence of Dr. Ampil, which is an element of the principle of corporate negligence. 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 217634 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. In fine, as there was no dispute over the RTC finding that PSI and Dr. Ampil had no employer-employee relationship, such finding became final and conclusive even to this Court. Cayao-Lasam vs. Spouses Ramolete [ G.R. No. 159132. December 18, 2008 ] FACTS: 3 months pregnant Editha Ramolete was brought to Lorma Medical Center (LMC) due to vaginal bleeding upon advise of Dr. Cayao-Lasam. A pelvic sonogram was then conducted which revealed the fetus weak cardiac pulsation. She then repeated it the next day. Dr. Cayao-Lasam advised her to undergo a D&C procedure (raspa). Editha again was brought to LMC as she was vomiting and has several abdominal pains. Drs. Cruz, Mayo and Komiya informed Editha that there was a dead fetus in the latter’s womb. The case was filed before the PRC (admin case) to revoke the license of Dr. Cayao-Lasam. Dr. Cayao-Lasam CONTENTION: her pregnancy is not a normal pregnancy (ectopic pregnancy). Board of Medicine: Dr. not liable. PRC: Dr. is liable. RULING: 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 8 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ patient is injured in body or in health, constitutes actionable malpractice. As to this aspect of medical malpractice, the determination of the reasonable level of care and the breach thereof, expert testimony is essential. Further, 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. Dr. Cayao-Lasam, 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. According to him, his diagnosis of Editha’s case was "Ectopic Pregnancy Interstitial (also referred to as Cornual), Ruptured." From the testimony of the expert witness and the reasons given by him, it is evident that the D&C procedure was not the proximate cause of the rupture of Editha’s uterus. When complainant was discharged on July 31, 1994, herein respondent advised her to return on August 4, 1994 or four (4) days after the D&C. This advise was clear in complainant’s Discharge Sheet. However, complainant failed to do so. This being the case, the chain of continuity as required in order that the doctrine of proximate cause can be validly invoked was interrupted. Had she returned, the respondent could have examined her thoroughly. 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. SC granted this and believed the expert witness Dr. Manalo because he was the only expert witness presented. Spouses Flores vs. Spouses Pineda [ G.R. No. 158996. November 14, 2008 ] FACTS: Teresita Pineda, 51 and unmarried complained of general body weakness, loss of appetite, frequent urination and thirst, and on-and-off vaginal bleeding. Dr. Fredelicto advised her to return back but she did not. She then went to Dr. Flores and ordered her admission to the hospital for a D&C operation to be performed by his wife Dra. Flores. Despite the presence of diabetes type II, they continued the D&C operation. Insulin was administered on her but due to complications induced by diabetes, Teresita died. RULING: Element of Injury diabetes and its complications were foreseeable harm that should have been taken into consideration by the petitioner spouses. If a patient suffers from some disability that increases the magnitude of risk to him, that disability must be taken into account so long as it is or should have been known to the physician. ↓ Here, the Dr. FAILED to take precaution since they proceeded with the D&C. Proximate cause Stress, whether physical or emotional, is a factor that can aggravate diabetes; a D&C operation is a form of physical stress. The decision to proceed with the D&C operation, notwithstanding Teresita's hyperglycemia and without adequately preparing her for the procedure, was 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. 9 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ Lucas vs. Tuaño [ G.R. No. 178763. April 21, 2009 ] FACTS: Peter Lucas first consulted Dr. Tuano on a complaint of soreness and redness on his right eye. It was found that he was suffering from conjunctivitis or “sore eyes” and prescribed Spersacet-C. His condition worsened and it had progressed to Epidemic Kerato Conjunctivitis (EKC), a viral infection. He was prescribed the use of Maxitrol, a steroid-based eye drop. However, it worsened over time. Four months later, he suffered swelling on his right eyeball, headaches, nausea and blindness on the right eye. He consulted another doctor - Dr. Batungbacal's diagnosis was Glaucoma O.D. He recommended Laser Trabeculoplasty for Peter's right eye. Peter sued Dr. Tuano for prescribing Maxitrol that caused him to suffer more because of the adverse reaction of the drug. RULING: Expert Witness Just as with the elements of duty and breach of the same, in order to establish the proximate cause [of the injury] by a preponderance of the evidence in a medical malpractice action, [the patient] must similarly use expert testimony, because the question of whether the alleged professional negligence caused [the patient's] injury is generally one for specialized expert knowledge beyond the ken of the average layperson; using the specialized knowledge and training of his field, the expert's role is to present to the [court] a realistic assessment of the likelihood that [the physician's] alleged negligence caused [the patient's] injury. From the foregoing, it is apparent that medical negligence cases are best proved by opinions of expert witnesses belonging in the same general neighborhood and in the same general line of practice as defendant physician or surgeon. There was absolute failure on the part of petitioners to present any expert testimony to establish: (1) the standard of care to be implemented by competent physicians in treating the same condition as Peter's under similar circumstances; (2) that, in his treatment of Peter, Dr. Tuaño failed in his duty to exercise said standard of care that any other competent physician would use in treating the same condition as Peter's under similar circumstances; and (3) that the injury or damage to Peter's right eye, i.e., his glaucoma, was the result of his use of Maxitrol, as prescribed by Dr. Tuaño. Petitioners' failure to prove the first element alone is already fatal to their cause. This Court has no yardstick upon which to evaluate or weigh the attendant facts of this case to be able to state with confidence that the acts complained of, indeed, constituted negligence and, thus, should be the subject of pecuniary reparation. The result is not determinative of the performance [of the physician] and he is not required to be infallible. Professional Services Inc. vs. CA and Agana [ G.R. No. 126297. February 02, 2010 ] 2nd Motion for Reconsideration FACTS: RULING: This Decision is only pro ha vice “for this case only”. It does not apply to them but only to PSI. 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. 10 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ Li vs. Spouses Soliman [ G.R. No. 165279. June 07, 2011 ] (Landmark Case - 9/15 affirmed, 5 dissented, and 1 abstain) FACTS: Angelica Soliman, 11-year old underwent a biopsy at St. Luke’s and it showed that she was suffering from a cancer of the bone. Following this diagnosis, Angelica’s right leg was amputated by Dr. Tamayo in order to remove the tumor. To avoid further infection, chemotherapy was suggested by Dr. Tamayo and referred her to Dr. Rubi Li, a medical oncologist. 11 days after the cycle, she died. St. Luke’s: cause of death is cancer not the chemotherapy. PNP’s findings: cause of death is “Hypovolemic shock secondary to multiple organ hemorrhages and Disseminated Intravascular Coagulation” Sps Soliman - their daughter died because of the chemotherapy; points to some probable consequences if Angelica had not undergone chemotherapy. RULING: Was there sufficient informed consent? The deference of courts to the expert opinion of qualified physicians stems from the former’s realization that the latter possess unusual technical skills which laymen in most instances are incapable of intelligently evaluating, hence the indispensability of expert testimonies. The physician is not expected to give the patient a short medical education, the disclosure rule only requires of him a reasonable explanation, which means generally informing the patient in nontechnical terms as to what is at stake; the therapy alternatives open to him, the goals expectably to be achieved, and the risks that may ensue from particular treatment or no treatment. ↓ Dr. Li gave the proper information to the patient intelligently. Dissenting Opinion (Justice Carpio): Patient-Inclined -scope must be inclined to the patient Aquino vs. Heirs of Calayag [ G.R. No. 158461. August 22, 2012 ] FACTS: Raymunda Calayag went into labor pains and they were advised by Dr. Unite to have a caesarean section at the Sacred Heart Hospital (SHH) owned by Dr. Reyes. There, Raymunda was admitted. Dr. Aquino, anesthesiologist, injected anesthesia on her spine to prepare her for labor. Later on, Dr. Unite delivered a stillborn eight month-old baby. After a while she suffered heart attack. ↓ Resuscitated ↓ Comatose ↓ Died 15 days after being discharge Rodrigo (H) presented Dr. Libarnes and Dr. Chua: Dr. Libarnes- explained that it was cyanosis or lack of oxygen in the brain that caused Raymunda's vegetative state. Her brain began to starve for oxygen from the moment she suffered cardio-respiratory arrest during caesarean section. That arrest, said Dr. Libarnes, could in turn be traced to the anesthetic accident that resulted when Dr. Aquino placed her under anesthesia. Dr. Chua, on the other hand, testified that Raymunda's surgical wound would not have split open if it had been properly closed. Dr. Unite and Dr. Aquino presented Dr. Reyes (hospital OWNER), their co-defendant, who practiced general surgery. Dr. Reyes testified that Raymunda's cardio-respiratory arrest could have been caused by factors other than high spinal anesthesia, like sudden release of intra-abdominal pressure and amniotic fluid embolism. Insofar as Raymunda's dehiscence or splitting open of wound was concerned, Dr. Reyes testified that Raymunda's poor nutrition as well as the medication contributed to the dehiscence. 11 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ RULING: Dr. Reyes’ as Expert Witness It cannot regard him as a neutral witness. Given that he himself was a defendant in the case, he had a natural bias for testifying to favor his co-defendants. Further, since he had no opportunity to actually examine Raymunda, Dr. Reyes could only invoke textbook medical principles that he could not clearly and directly relate to the patient's specific condition. Liability of Hospital No liability since no EE-ER relationship. As for Dr. Reyes, the hospital owner, there appears no concrete proof to show that Dr. Unite and Dr. Aquino were under the hospital's payroll. Indeed, Dr. Aquino appeared to be a government physician connected with the Integrated Provincial Health Office of Bulacan. Dr. Unite appeared to be a self- employed doctor. The hospital allowed these doctors to operate on their patients, using its operating room and assisting staffs for a fee. No evidence has been presented that Raymunda suffered her fate because of defective hospital facilities or poor staff support to the surgeons. Cereno vs. CA [ G.R. No. 167366. September 26, 2012 ] FACTS: Raymond was a victim of stabbing incident and rushed to the ER of Bicol Regional Medical Center, he was attended by Nurse Balares and Dr. Realuyo. After giving initial medical treatment to Raymond, Dr. Realuyo recommended emergency exploratory laparotomy, to which he asked Raymond‘s parents to procure Type O blood required for the operation. Because there were no other available anaesthesiologists to assist in the operation, Doctors Zafe and Cereno decided to defer the operation. (triplets ongoing operation) They likewise conducted an examination on Raymond and found that the latter‘s blood pressure was normal and nothing in him was significant. During the operation and after they opened Raymond‘s thoracic cavity, they found a puncture at the inferior pole of the left lung. In his testimony, Dr. Cereno stated that considering the loss of blood suffered by Raymond, he did not immediately transfuse blood because he had to control the bleeders first. Raymond suffered a cardiac arrest and was later on pronounced dead. RULING: Elements: Medical Malpractice 1) DUTY Standby anesthesiologist There is nothing in the testimony of Dr. Tatad, or in any evidence on the record for that matter, which shows that the petitioners were aware of the "BRMC protocol" that the hospital keeps a standby anesthesiologist available on call. Indeed, other than the testimony of Dr. Tatad, there is no evidence that proves that any such "BRMC protocol" is being practiced by the hospital’s surgeons at all. ↓ cannot hold petitioners accountable for not complying with something that they, in the first place, do not know. ↓ Given that Dr. Tatad was already engaged in another urgent operation and that Raymond was not showing any symptom of suffering from major blood loss requiring an immediate operation, We find it reasonable that petitioners decided to wait for Dr. Tatad to finish her surgery and not to call the standby anesthesiologist anymore. 4) PROXIMATE CAUSE ↓ They also failed to prove that it was petitioners’ fault that caused the injury. Their cause stands on the mere assumption that Raymond’s life would have been saved had petitioner surgeons immediately operated on him; had the blood been cross-matched immediately and had the blood been transfused immediately. There was, however, no proof presented that Raymond’s life would have been saved had those things been done. 12 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ Jarcia, Jr. vs. People [ G.R. No. 187926. February 15, 2012 ] CRIMINAL CASE - serious physical injuries FACTS: Roy, Jr. was hit by a taxicab and he was rushed to the hospital. An x-ray of the victim’s ankle was ordered and it showed no fracture by Dr. Jarcia. Then, Dr. Bastan entered the emergency room and informed Mrs. Santiago (M) that since it was only the ankle that was hit, there was no need to examine the upper leg. A few days later, Roy, Jr. developed fever, swelling of the right leg and misalignment of the right foot, so Mrs. brought him back to the hospital and the x-ray revealed a right mid tibial fracture and a linear hairline fracture in the shaft of the bone. RULING: 2nd element: BREACH Physician negligently departed from care. NEGLIGENCE - the failure to observe for the protection of the interests of another person that degree of care, precaution, and vigilance which the circumstances justly demand, whereby such other person suffers injury. The elements of simple negligence are: (1) that there is lack of precaution on the part of the offender, and (2) that the damage impending to be caused is not immediate or the danger is not clearly manifest.16 In this case, the Court is not convinced with moral certainty that the petitioners (doctors) are guilty of reckless imprudence or simple negligence. The elements thereof were not proved by the prosecution beyond reasonable doubt. Ordinarily, only physicians and surgeons of skill and experience are competent to testify as to whether a patient has been treated or operated upon with a reasonable degree of skill and care. However, testimony as to the statements and acts of physicians, external appearances, and manifest conditions which are observable by any one may be given by non-expert witnesses. Hence, in cases where the res ipsa loquitur is applicable, the court is permitted to find a physician negligent upon proper proof of injury to the patient, without the aid of expert testimony, where the court from its fund of common knowledge can determine the proper standard of care. Where common knowledge and experience teach that a resulting injury would not have occurred to the patient if due care had been exercised, an inference of negligence may be drawn giving rise to an application of the doctrine of res ipsa loquitur without medical evidence, which is ordinarily required to show not only what occurred but how and why it occurred. In the case at bench, we give credence to the testimony of Mrs. Santiago by applying the doctrine of res ipsa loquitur. Huang vs. Philippine Hoteliers Inc. [ G.R. No. 180440. December 05, 2012 ] FACTS: Dr. Huang, a dermatologist, was invited by her friend Delia Goldberg, a registered guest at the Dusit Hotel, for a swim in the hotel’s pool. They started bathing at 5:00 PM. At around 7:00 PM, they were informed by the pool attendant that the pool area was about to be closed. They then went to the shower room. When they came out of the said room, the entire pool area was already pitch black. They walked towards the main door leading to the hotel, but the door was locked. 10 minutes of waiting followed. Petitioner then began to walk around to look for a house phone. A folding wooden counter top then fell on petitioner’s head, knocking her down almost unconscious. Once they were rescued by the hotel’s personnel, petitioner demanded the hotel physician’s services. Dr. Violeta Dalumpines introduced herself as the hotel physician, but instead of providing the needed medical assistance, Dr. Dalumpines presented a “Waiver” and demanded that petitioner sign the same. The latter refused to do so. Upon arriving home, petitioner started to feel extraordinary dizziness accompanied by an uncomfortable feeling in her stomach, which lasted until the following day. Petitioner was constrained to stay at home, thus, missing all her important appointments with her patients. She also began experiencing "on" and "off" severe headaches that caused her three (3) sleepless nights. 13 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ She consulted several doctors and all of the doctors found that petitioner is suffering from a serious brain injury. Contention: who goes in a hotel without a "bukol" or hematoma and comes out of it with a "bukol" or hematoma is a clear case of res ipsa loquitur RULING: RES IPSA LOQUITUR NOT APPLICABLE The doctrine of res ipsa loquitur applies where, (1) the accident was of such character as to warrant an inference that it would not have happened except for the defendant’s negligence; (2) the accident must have been caused by an agency or instrumentality within the exclusive management or control of the person charged with the negligence complained of; and (3) the accident must not have been due to any voluntary action or contribution on the part of the person injured. In the case at bench, even granting that respondents PHI and DTPCI’s staff negligently turned off the lights and locked the door, the folding wooden countertop would still not fall on petitioner’s head had she not lifted the same. Although the folding wooden countertop is within the exclusive management or control of respondents PHI and DTPCI, the falling of the same and hitting the head of petitioner was not due to the negligence of the former. As found by both lower courts, the folding wooden countertop did not fall on petitioner’s head without any human intervention. Records showed that petitioner lifted the said folding wooden countertop that eventually fell and hit her head. The same was evidenced by the, (1) 11 June 1995 handwritten certification of petitioner herself; (2) her Letter dated 30 August 1995 addressed to Mr. Yoshikazu Masuda (Mr. Masuda), General Manager of Dusit Hotel; and, (3) Certification dated 7 September 1995 issued to her by Dr. Dalumpines upon her request, which contents she never questioned. This Court is not unaware that in petitioner’s Complaint and in her open court testimony, her assertion was, "while she was passing through the counter door, she was suddenly knocked out by a hard and heavy object, which turned out to be the folding wooden countertop." However, in her open court testimony, particularly during cross-examination, petitioner confirmed that she made such statement that "she lifted the hinge massive wooden section of the counter near the swimming pool." In view thereof, this Court cannot acquiesce petitioner’s theory that her case is one of res ipsa loquitur as it was sufficiently established how petitioner obtained that "bukol" or "hematoma." Cabugao vs. People [ G.R. No. 163879. July 30, 2014 ] FACTS: Rodolfo Palma who complained of abdominal pain was brought to the clinic of Dr. Cabugao, a general practitioner specializing in family medicine. Dr. Cabugao did a rectal examination with the initial impression that it was a case of Acute Appendicitis and referred the case to Dr. Ynzon, a surgeon. There was administration of massive antibiotics and pain reliever. Palma was placed on observation for 24 hours. The nurses in-duty relayed Palma’s worsening conditions to Dr. Ynzon who merely have orders via telephone. Palma’s temperature soared to 42 degrees, had convulsions and finally died. Underlying cause: SEPTICEMIA (ACUTE APPENDICITIS) RULING: RECKLESS IMPRUDENCE Reckless imprudence consists of voluntarily doing or failing to do, without malice, an act from which material damage results by reason of an inexcusable lack of precautionon the part of the person performing or failing to perform such act. 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 bewithout 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. 5th element: inexcusable lack of precaution; intent not necessary 14 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ With respect to Dr. Ynzon, all the requisites of the offense have been clearly established by the evidence on record. The court a quoand the appellate court were one in concluding that Dr. Ynzon failed to observe the required standard of care expected from doctors. CONSPIRACY While both appeared to be the attending physicians of JR during his hospital confinement, it cannot be said that the finding of guilt on Dr. Ynzon necessitates the same finding on the co-accused Dr. Cabugao. Conspiracy is inconsistent with the idea of a felony committed by means of culpa. Thus, the accused- doctors to be found guilty of reckless imprudence resulting in homicide, it must be shown that both accused-doctors demonstratedan act executed without malice or criminal intent – but with lack of foresight, carelessness, or negligence. Noteworthy, the evidence on record clearly points to the reckless imprudence of Dr. Ynzon; however, the same cannot be said in Dr. Cabugao's case. Dr. CABUGAO NOT NEGLIGENT The referral of JR to Dr. Ynzon, a surgeon, is actually an exercise of precaution as he knew that appendicitis is not within his scope of expertise. This clearly showed that he employed the best of his knowledge and skill in attending to JR's condition, even after the referral of JR to Dr. Ynzon. Dela Torre vs. Imbuido [G.R. No. 192973. September 29, 2014] FACTS: This involved 2 operations of Carmen. She was brought to the operating room for her caesarian section operation, to be performed by Dr. Nestor. By 5:30pm of the same day, Pedrito was informed of his wife’s delivery of a baby boy. The morning after, Carmen experienced abdominal pain and difficulty in urinating. She was diagnosed with UTI. At around 3:00 p.m. on February 12, 1992, Carmen had her second operation (exploratory laparotomy). The condition of Carmen, however, did not improve. It instead worsened that on February 13, 1992, she vomited dark red blood. At 9:30 p.m. on the same day, Carmen died. Cause of Death: "shock due to peritonitis, severe, with multiple intestinal adhesions; Status post C[a]esarian Section and Exploratory Laparotomy." RULING: PROXIMATE CAUSE The claimant must prove not only the injury but also the physician’s fault, and that such 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, which the Court finds absent in the case at bar. EXPERT WITNESS Considering that it was not duly established that Dr. Patilano practiced and was an expert in the fields that involved Carmen’s condition, he could not have accurately identified the said degree of care, skill, diligence and the medical procedures that should have been applied by her attending physicians. Solidum vs. People [ G.R. No. 192123. March 10, 2014 ] FACTS: Gerald Albert Gercayo was born with an imperforate anus (no hole sa 🍑). 2 days after his birth, he underwent colostomy. 3 years after, he was admitted in Ospital ng Maynila for a pull-through operation (binutasan ang 🍑). During the operation, he experienced slow heart rate and went into a coma. He regained consciousness after a month and could no longer see, hear or move. His mother filed a criminal complaint - reckless imprudence to Dr. Solidum (anesthesiologist). RTC: Solidum failed to monitor and to properly regulate the level of anesthetic agent administered on Gerald. 15 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ RULING: RECKLESS IMPRUDENCE RESULTING IN SERIOUS PHYSICAL INJURIES Inexcusable Lack of Precaution The Prosecution did not prove the elements of reckless imprudence beyond reasonable doubt because the circumstances cited by the CA were insufficient to establish that Dr. Solidum had been guilty of inexcusable lack of precaution in monitoring the administration of the anesthetic agent to Gerald. BREACH EXPERT WITNESS Here, the Prosecution presented no witnesses with special medical qualifications in anesthesia to provide guidance to the trial court on what standard of care was applicable. It would consequently be truly difficult, if not impossible, to determine whether the first three elements of a negligence and malpractice action were attendant. The existence of the probability about other factors causing the hypoxia has engendered in the mind of the Court a reasonable doubt as to Dr. Solidum’s guilt, and moves us to acquit him of the crime of reckless imprudence resulting to serious physical injuries. ACQUITTED Dr. Solidum RES IPSA LOQUITUR -Absence of first element The Court considers the application here of the doctrine of res ipsa loquitur inappropriate. Although it should be conceded without difficulty that the second and third elements were present, considering that the anesthetic agent and the instruments were exclusively within the control of Dr. Solidum, and that the patient, being then unconscious during the operation, could not have been guilty of contributory negligence, the first element was undeniably wanting. 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 pull-through 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. LIABILITY OF HOSPITAL Verily, no person can be prejudiced by a ruling rendered in an action or proceeding in which he was not made a party. Such a rule would enforce the constitutional guarantee of due process of law. Ospital ng Maynila not liable. Firstly, pursuant to Article 103 of the Revised Penal Code, Ospital ng Maynila must be shown to be a corporation "engaged in any kind of industry." The term industry means any department or branch of art, occupation or business, especially one that employs labor and capital, and is engaged in industry. However, Ospital ng Maynila, being a public hospital, was not engaged in industry conducted for profit but purely in charitable and humanitarian work. Secondly, assuming that Ospital ng Maynila was engaged in industry for profit, Dr. Solidum must be shown to be an employee of Ospital ng Maynila acting in the discharge of his duties during the operation on Gerald. Yet, he definitely was not such employee but a consultant of the hospital. And, thirdly, assuming that civil liability was adjudged against Dr. Solidum as an employee (which did not happen here), the execution against him was unsatisfied due to his being insolvent. 16  Based on the lectures of Atty. Francis Talon, RN, MD ㎡ Alano vs. Magud-Logmao [ G.R. No. 175540. April 14, 2014 ] skipped Casumpang vs. Cortejo [ G.R. No. 171127. March 11, 2015 ] Discussed in Physician-Patient Relationship FACTS: Edmer (11 year old) experienced difficulty in breathing, chest pain, stomach pain, and fever. He was diagnosed with pneumonia by Dr. Casumpang (pediatrician). In the morning, Edmer vomited "phlegm with blood streak" prompting Nelson (F) to request for a doctor at the nurses’ station. Forty-five minutes later, Dr. Ruby Miranda-Sanga (Dr. Sanga), one of the resident physicians of SJDH, arrived. She claimed that although aware that Edmer had vomited "phlegm with blood streak," she failed to examine the blood specimen because the respondent washed it away. She then advised Nelson (F) to preserve the specimen for examination. Dr. Sanga then examined Edmer’s "sputum with blood" and noted that he was bleeding. Suspecting that he could be afflicted with dengue, she inserted a plastic tube in his nose, drained the liquid from his stomach with ice cold normal saline solution, and gave an instruction not to pull out the tube, or give the patient any oral medication. At 4:40 in the afternoon, Dr. Sanga called up Dr. Casumpang at his clinic and told him about Edmer’s condition.22 Upon being informed, Dr. Casumpang ordered several procedures done including: hematocrit, hemoglobin, blood typing, blood transfusion and tourniquet tests. The blood test results came at about 6:00 in the evening. Dr. Sanga advised Edmer’s parents that the blood test results showed that Edmer was suffering from "Dengue Hemorrhagic Fever." One hour later, Dr. Casumpang arrived at Edmer’s room and he recommended his transfer to the Intensive Care Unit (ICU) At 12:00 midnight, Edmer, accompanied by his parents and by Dr. Casumpang, was transferred to Makati Medical Center. Dr. Casumpang immediately gave the attending physician the patient’s clinical history and laboratory exam results. Upon examination, the attending physician diagnosed "Dengue Fever Stage IV" that was already in its irreversible stage. Edmer died at 4:00 in the morning of April 24, 1988. RULING: 1st ELEMENT - DUTY (prove the standard of care - provide expert witness) 2nd ELEMENT - BREACH OF DUTY Breach of duty occurs when the doctor fails to comply with, or improperly performs his duties under professional standards. This determination is both factual and legal, and is specific to each individual case. A determination of whether or not the petitioning doctors met the required standard of care involves a question of mixed fact and law; it is factual as medical negligence cases are highly technical in nature, requiring the presentation of expert witnesses to provide guidance to the court on matters clearly falling within the domain of medical science, and legal, insofar as the Court, after evaluating the expert testimonies, and guided by medical literature, learned treatises, and its fund of common knowledge, ultimately determines whether breach of duty took place. Whether or not Dr. Casumpang and Dr. Sanga committed a breach of duty is to be measured by the yardstick of professional standards observed by the other members of the medical profession in good standing under similar circumstances. It is in this aspect of medical malpractice that expert testimony is essential to establish not only the professional standards observed in the medical community, but also that the physician’s conduct in the treatment of care falls below such standard. WRONGFUL DIAGNOSIS AS BREACH OF STANDARD OF CARE GR: No. wrongful diagnosis is not considered as breach of standard of care 17 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ EXC: when the physician’s erroneous diagnosis was the result of negligent conduct (e.g., neglect of medical history, failure to order the appropriate tests, failure to recognize symptoms), it becomes an evidence of medical malpractice. neglect of medical history (gave a pregnant woman a medicine that caused the unaliving of a fetus) failure to order the appropriate tests (syringe - HIV) failure to recognize symptoms -present in this case - failed to recognize the symptoms of dengue. Here, the failure to recognize is INTENTIONAL - considered as breach In the present case, evidence on record established that in confirming the diagnosis of bronchopneumonia, Dr. Casumpang selectively appreciated some and not all of the symptoms presented, and failed to promptly conduct the appropriate tests to confirm his findings. In sum, Dr. Casumpang failed to timely detect dengue fever, which failure, especially when reasonable prudence would have shown that indications of dengue were evident and/or foreseeable, constitutes negligence. DR. MIRANDA NOT LIABLE WITH MEDICAL MALPRACTICE (not independently negligent; limited authority) Dr. Sanga was not independently negligent. Although she had greater patient exposure, and was subject to the same standard of care applicable to attending physicians, we believe that a finding of negligence should also depend on several competing factors, among them, her authority to make her own diagnosis, the degree of supervision of the attending physician over her, and the shared responsibility between her and the attending physicians. In this case, before Dr. Sanga attended to Edmer, both Dr. Livelo and Dr. Casumpang had diagnosed Edmer with bronchopneumonia. In her testimony, Dr. Sanga admitted that she had been briefed about Edmer’s condition, his medical history, and initial diagnosis;79 and based on these pieces of information, she confirmed the finding of bronchopneumonia. Dr. Sanga likewise duly reported to Dr. Casumpang, who admitted receiving updates regarding Edmer’s condition.80 There is also evidence supporting Dr. Sanga’s claim that she extended diligent care to Edmer. In fact, when she suspected – during Edmer’s second episode of bleeding– that Edmer could be suffering from dengue fever, she wasted no time in conducting the necessary tests, and promptly notified Dr. Casumpang about the incident. Indubitably, her medical assistance led to the finding of dengue fever. HOSPITAL’s LIABILITY No EE-ER relationship As a rule, hospitals are not liable for the negligence of its independent contractors. However, it may be found liable if the physician or independent contractor acts as an ostensible agent of the hospital. This exception is also known as the "doctrine of apparent authority." ↓ Are they acting as an agent of the hospital? Are they liable? HOSPITAL is SOLIDARY LIABLE based on the apparent authority - met in this case A) Hospital manifestataions In this case, the court considered the act of the hospital of holding itself out as provider of complete medical care, and considered the hospital to have impliedly created the appearance of authority. B) Patient’s reliance Thus, this requirement is deemed satisfied if the plaintiff can prove that he/she relied upon the hospital to provide care and treatment, rather than upon a specific physician. In this case, we shall limit the 18 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ determination of the hospital’s apparent authority to Dr. Casumpang, in view of our finding that Dr. Sanga is not liable for negligence. THEREFORE: Hospital is made liable Cruz vs. Agas, Jr. [ G.R. No. 204095. June 15, 2015 ] FACTS: Dr. Cruz went for a medical check-up and underwent stool, urine, blood, and other body fluid tests; he was sent to the Gastro-Enterology Department for a scheduled gastroscopy and colonoscopy; that because the specialist assigned to perform the procedure was nowhere to be found, he gave the colonoscopy results to the attending female anesthesiologist for the information and consideration of the assigned specialist; that, thereafter, he was sedated and the endoscopic examination was carried out; that when he regained consciousness, he felt that something went wrong during the procedure because he felt dizzy, had cold clammy perspiration and experienced breathing difficulty; that he could not stand or sit upright because he felt so exhausted and so much pain in his abdomen; that when he was about to urinate in the comfort room, he collapsed; that he tried to consult the specialist who performed the colonoscopy but he was nowhere to be found; and that his cardiologist, Dra. Agnes Del Rosario, was able to observe his critical condition and immediately referred him to the surgical department which suspected that he had hemorrhage in his abdomen and advised him to undergo an emergency surgical operation. Dr. Cruz further averred that he agreed to the operation and upon waking up at the ICU he found out that the doctors did an exploratory laparatomy because of the internal bleeding; that he learned that the doctors cut a portion of the left side of his colon measuring 6-8 inches because it had a partial tear of the colonic wall which caused the internal bleeding; that despite the painkillers, he was under tremendous pain in the incision area during his recovery period in the ICU and had fever; and that he had intravenous tubes attached to his arms, subclavian artery on the left part of his chest and a nasogastric tube through his nose. RULING: RES IPSA LOQUITUR Not applicable - agreed with Dr. Agas In this case, the Court agrees with Dr. Agas that his purported negligence in performing the colonoscopy on Dr. Cruz was not immediately apparent to a layman to justify the application of res ipsa loquitur doctrine. Dr. Agas was able to establish that the internal bleeding sustained by Dr. Cruz was due to the abnormal condition and configuration of his sigmoid colon which was beyond his control considering that the said condition could not be detected before a colonoscopic procedure. Dr. Agas adequately explained that no clinical findings, laboratory tests, or diagnostic imaging, such as x-rays, ultrasound or computed tomography (CT) scan of the abdomen, could have detected this condition prior to an endoscopic procedure. Rosit vs. Davao Doctor’s Hospital [ G.R. No. 210445. December 07, 2015 ] FACTS: Nila Rosit figured in a motorcycle accident. The x-ray taken at the Davao Doctors Hospital showed that he fractured his jaw. He was then referred to Dr. Gestuvo (surgeon). During the operation, Dr. Gestuvo used a metal plate fastened to the jaw with metal screws to immobilize the mandible. As the operation required the smallest screws available, Dr. Gestuvo cut the screws on hand to make them smaller. Dr. Gestuvo knew that there were smaller titanium screws available in Manila, but did not so 19 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ inform Rosit supposing that the latter would not be able to afford the same. Following the procedure, Rosit could not properly open and close his mouth and was in pain. X-rays done on Rosit two (2) days after the operation showed that the fracture in his jaw was aligned but the screws used on him touched his molar. Given the X-ray results, Dr. Gestuvo referred Rosit to a dentist. The dentist who checked Rosit, Dr. Pangan, opined that another operation is necessary and that it is to be performed in Cebu. In Cebu, Dr. Pangan removed the plate and screws thus installed by Dr. Gestuvo and replaced them with smaller titanium plate and screws. Dr. Pangan also extracted Rosit's molar that was hit with a screw and some bone fragments. Three days after the operation, Rosit was able to eat and speak well and could open and close his mouth normally. On his return to Davao, Rosit demanded that Dr. Gestuvo reimburse him for the cost of the operation and the expenses he incurred in Cebu. RULING: RES IPSA LOQUITUR The first element was sufficiently established when Rosit proved that one of the screws installed by Dr. Gestuvo struck his molar. It was for this issue that Dr. Gestuvo himself referred Rosit to Dr. Pangan. In fact, the affidavit of Dr. Pangan presented by Dr. Gestuvo himself before the trial court narrated that the same molar struck with the screw installed by Dr. Gestuvo was examined and eventually operated on by Dr. Pangan. Dr. Gestuvo cannot now go back and say that Dr. Pangan treated a molar different from that which was affected by the first operation. Anent the second element for the res ipsa loquitur doctrine application, it is sufficient that the operation which resulted in the screw hitting Rosit's molar was, indeed, performed by Dr. Gestuvo. No other doctor caused such fact. Third element not met: Nevertheless, Dr. Pangan's participation could not have contributed to the reality that the screw that Dr. Gestuvo installed hit Rosit's molar. Dr. Gestuvo knew that the screws he used on Rosit were too large as, in fact, he cut the same with a saw. He also stated during trial that common sense dictated that the smallest screws available should be used. More importantly, he also knew that these screws were available locally at the time of the operation. Yet, he did not avail of such items and went ahead with the larger screws and merely sawed them off. Even assuming that the screws were already at the proper length after Dr. Gestuvo cut the same, it is apparent that he negligently placed one of the screws in the wrong area thereby striking one of Rosit's teeth. DOCTRINE OF INFORMED CONSENT Violated - What is more damning for Dr. Gestuvo is his failure to inform Rosit that such smaller screws were available in Manila, albeit at a higher price. Li v. Soliman made the following disquisition on the relevant Doctrine of Informed Consent in relation to medical negligence cases, to wit: The doctrine of informed consent within the context of physician-patient relationships goes far back into English common law. x x x From a purely ethical norm, informed consent evolved into a general principle of law that a physician has a duty to disclose what a reasonably prudent physician in the medical community in the exercise of reasonable care would disclose to his patient as to whatever grave risks of injury might be incurred from a proposed course of treatment, so that a patient, exercising ordinary care for his own welfare, and faced with a choice of undergoing the proposed treatment, or alternative treatment, or none at all, may intelligently exercise his judgment by reasonably balancing the probable risks against the probable benefits. xxxx 20 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ There are four essential elements a plaintiff must prove in a malpractice action based upon the doctrine of informed consent: "(1) the physician had a duty to disclose material risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a direct and proximate result of the failure to disclose, the patient consented to treatment she otherwise would not have consented to; and (4) plaintiff was injured by the proposed treatment." The gravamen in an informed consent case requires the plaintiff to "point to significant undisclosed information relating to the treatment which would have altered her decision to undergo it." (emphasis supplied) The four adverted essential elements above are present here. First, Dr. Gestuvo clearly had the duty of disclosing to Rosit the risks of using the larger screws for the operation. This was his obligation as the physician undertaking the operation. Second, Dr. Gestuvo failed to disclose these risks to Rosit, deciding by himself that Rosit could not afford to get the more expensive titanium screws. Third, had Rosit been informed that there was a risk that the larger screws are not appropriate for the operation and that an additional operation replacing the screws might be required to replace the same, as what happened in this case, Rosit would not have agreed to the operation. It bears pointing out that Rosit was, in fact, able to afford the use of the smaller titanium screws that were later used by Dr. Pangan to replace the screws that were used by Dr. Gestuvo. Fourth, as a result of using the larger screws, Rosit experienced pain and could not heal properly because one of the screws hit his molar. This was evident from the fact that just three (3) days after Dr. Pangan repeated the operation conducted by Dr. Gestuvo, Rosit was pain-free and could already speak. This is compared to the one (1) month that Rosit suffered pain and could not use his mouth after the operation conducted by Dr. Gestuvo until the operation of Dr. Pangan. Without a doubt, Dr. Gestuvo is guilty of withholding material information which would have been vital in the decision of Rosit in going through with the operation with the materials at hand. Thus, Dr. Gestuvo is also guilty of negligence on this ground. Borromeo vs. Family Care Hospital [ G.R. No. 191018. January 25, 2016 ] FACTS: Carlos Borromeo (Borromeo) brought his wife Lilian Borromeo (Lilian) to the Family Care Hospital (FCH) because she had been complaining of acute pain at the lower stomach area and fever for two days. Dr. Ramon Inso (Dr. Inso) suspected that Lilian might be suffering from acute appendicitis. However, there was insufficient data to rule out other possible causes and to proceed with an appendectomy. Lilian abruptly developed an acute surgical abdomen. Dr. Inso decided to conduct an exploratory laparotomy on Lilian because of the findings on her abdomen and his fear that she might have a ruptured appendix. During the operation, Dr. Inso confirmed that Lilian was suffering from acute appendicitis. He proceeded to remove her appendix which was already infected and congested with pus. The operation was successful. Six hours after Lilian was brought back to her room, Dr. Inso was informed that her blood pressure was low. He immediately requested a blood transfusion. At this point, Dr. Inso suspected that Lilian had Disseminated Intravascular Coagulation (DIC), a blood disorder characterized by bleeding in many parts of her body caused by the consumption or the loss of the clotting factors in the blood. However, Dr. Inso did not have the luxury to conduct further tests because the immediate need was to resuscitate Lilian. Dr. Inso and the nurses performed CPR on Lilian. Dr. Inso also informed her family that there may be a need to re-operate on her, but she would have to be put in an Intensive Care Unit (ICU). Unfortunately, Family Care did not have an ICU because it was only a secondary hospital and was not required by the 21 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ Department of Health to have one. Dr. Inso then personally coordinated with the Muntinlupa Medical Center (MMC) which had an available bed. Upon reaching the MMC, a medical team was on hand to resuscitate. Unfortunately, Lilian passed away despite efforts to resuscitate her. RULING: MEDICAL MALPRACTICE Because medical malpractice cases are often highly technical, expert testimony is usually essential to establish: (1) the standard of care that the defendant was bound to observe under the circumstances; (2) that the defendant’s conduct fell below the acceptable standard; and (3) that the defendant’s failure to observe the industry standard caused injury to his patient. The expert witness must be a similarly trained and experienced physician. Thus, a pulmonologist is not qualified to testify as to the standard of care required of an anesthesiologist and an autopsy expert is not qualified to testify as a specialist in infectious diseases. Dr. Reyes is not an expert witness who could prove Dr. Inso’s alleged negligence. His testimony could not have established the standard of care that Dr. Inso was expected to observe nor assessed Dr. Inso’s failure to observe this standard. His testimony cannot be relied upon to determine if Dr. Inso committed errors during the operation, the severity of these errors, their impact on Lilian’s probability of survival, and the existence of other diseases/condition. RES IPSA LOQUITUR The petitioner cannot invoke the doctrine of res ipsa loquitur to shift the burden of evidence onto the respondent. Res ipsa loquitur, literally, “the thing speaks for itself;” is a rule of evidence that presumes negligence from the very nature of the accident itself using common human knowledge or experience. The rule is not applicable in cases such as the present one where the defendant’s alleged failure to observe due care is not immediately apparent to a layman. These instances require expert opinion to establish the culpability of the defendant doctor. It is also not applicable to cases where the actual cause of the injury had been identified or established. While this Court sympathizes with the petitioner’s loss, the petitioner failed to present sufficient convincing evidence to establish: (1) the standard of care expected of the respondent and (2) the fact that Dr. Inso fell short of this expected standard. Considering further that the respondents established that the cause of Lilian’s uncontrollable bleeding (and, ultimately, her death) was a medical disorder – Disseminated Intravascular Coagulation – we find no reversible errors in the CA’s dismissal of the complaint on appeal. Our Lady of Lourdes Hospital vs. Spouses Capanzana [ G.R. No. 189218. March 22, 2017 ] FACTS: Regina Capanzana (Regina) was scheduled for her third caesarean section. However, a week earlier, she went into active labor and was brought to Our Lady of Lourdes Hospital for an emergency C-section. She was found fit for anesthesia by Dr. Ramos and Dr. Santos after she responded negatively to questions about tuberculosis, rheumatic fever, and cardiac diseases. On that same day, she gave birth to a baby boy. The following day, Regina complained of a headache, a chilly sensation, restlessness, and shortness of breath. She asked for oxygen and later became cyanotic. After undergoing an x-ray, she was found to be suffering from pulmonary edema. When her condition still showed no improvement, Regina was transferred to the Cardinal Santos Hospital. The doctors thereat found that she was suffering from rheumatic heart disease mitral stenosis with mild pulmonary hypertension, which contributed to the onset of fluid in her lung tissue. This development resulted in cardiopulmonary arrest and, subsequently, brain damage. Regina lost the use of her speech, eyesight, hearing and limbs. She was discharged, still in a vegetative state. Respondent spouses Capanzana filed a complaint for damages against petitioner hospital. Respondents imputed negligence to Drs. Ramos and Santos for the latter's failure to detect the heart disease of Regina, resulting in failure not only to refer her to a cardiologist for cardiac clearance. They further stated that the nurses were negligent for not having promptly given oxygen, and that the hospital was equally negligent for not making available and accessible the oxygen unit on that same hospital floor at the time. 22 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ RULING: MEDICAL NEGLIGENCE There is a medical negligence on the part of the nurses of the hospital. In order to successfully pursue a claim in a medical negligence case, the plaintiff must prove that a health professional either failed to do something which a reasonably prudent health professional would have or have not done; and that the action or omission caused injury to the patient. Proceeding from this guideline, the plaintiff must show the following elements by a preponderance of evidence: duty of the health professional, breach of that duty, injury of the patient, and proximate causation between the breach and the injury. In this case, there was a delay in the administration of oxygen to the patient, caused by the delayed response of the nurses of petitioner hospital. They committed a breach of their duty to respond immediately to the needs of Regina, considering her precarious situation and her physical manifestations of oxygen deprivation. When Regina was gasping for breath and turning cyanotic, it was the duty of the nurses to intervene immediately by informing the resident doctor. Had they done so, proper oxygenation could have been restored and other interventions performed without wasting valuable time. That such high degree of care and responsiveness was needed cannot be overemphasized - considering that according to expert medical evidence in the records, it takes only five minutes of oxygen deprivation for irreversible brain damage to set in. They should have been prompted to respond immediately when Regina herself expressed her needs, especially in that emergency situation when it was not easy to determine with certainty the cause of her breathing difficulty. Thus, the nurses of the hospital committed medical negligence. HOSPITAL’S LIABILITY The hospital should be held liable. Under Article 2180, an employer like petitioner hospital may be held liable for the negligence of its employees based on its responsibility under a relationship of patria potestas. The employer may only be relieved of responsibility upon a showing that it exercised the diligence of a good father of a family in the selection and supervision of its employees. In this case, the hospital failed to discharge its burden of proving due diligence in the supervision of its nurses and is therefore liable for their negligence. There is no proof of actual supervision of the employees' work or actual implementation and monitoring of consistent compliance with the rules. Allarey vs. Dela Cruz [ G.R. No. 250919. November 10, 2021 ] FACTS: Marissa Baco (Marissa) died at 35 years old after giving birth prematurely to Julia Carla Allarey (Julia Carla) who died eventually. Marissa experienced bleeding while resting at home. At that time, the age of gestation of Marissa's fourth pregnancy was 30-31 weeks. Upon advice of Dr. Dela Cruz, she was brought to her clinic at MIKKO MEDICS. Dr. Dela Cruz conducted an internal examination on Marissa. She then endorsed her to MEMCI and instructed that she be immediately brought to the Operating Room/ Delivery Room (OR/DR) and was admitted at 6:00 pm. Marissa informed Jude that she experienced bleeding again and that she would be brought to the OR/DR. Later, Marissa called up Jude and told him that she was being denied readmission to the OR/DR unless a deposit of P10,000.00 was paid. Jude said that he would settle the matter once he arrived at the hospital. She again called him up to tell him that she had been readmitted to the OR/DR. A pediatrician came out from the OR/DR and asked him to go to the Nursery. There, he saw his premature baby Julia Carla in the incubator, struggling for her life. Jude was then told that certain procedures were being undertaken on Marissa. A nurse also came out of the OR/DR and asked him to sign a document which, without reading, he simply signed. Another nurse came out of the OR/DR and asked for blood units. Jude's sister went downstairs and learned that the blood units she paid for earlier 23 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ would be available after two hours as the hospital still had to source the blood from Fabella Hospital. Since the blood was urgently needed, they tried to look for type AB blood units but were not successful. At about 5:00 p.m., Jude was asked to go to the OR/DR where he witnessed Marissa die. In the morning, Jude went to MEMCI due to the pediatrician's urgent request for a ventilator for Julia Carla. After paying, Jude learned from the nurse that the ventilator would be delivered at 11:00 a.m.. It was past 12:00 p.m. when the ventilator was used. At 2:30 p.m., Julia Carla died. RULING: RES IPSA LOQUITUR - NOT APPLICABLE Placenta accreta is not the contemplated scenario to justify the application of the doctrine of res ipsa loquitur as this kind of complication in childbirth is not immediately apparent and, often times, not immediately diagnosed. Here, the medical condition of Marissa was not within the exclusive control of Dr. Dela Cruz Dr. Dela Cruz’s LIABILITY Admittedly, petitioners, who are the plaintiffs in the complaint for quasi-delict, failed to completely present their lone expert witness to substantiate their claim against Dr. Dela Cruz and MEMCI. Dr. Bausa failed to attend several settings for her cross-examination. Nonetheless, this fact alone does not preclude the Court from making its own determination of the rights and liabilities based on the overall evidence presented during trial. In the present case, it appears that Marissa died due to preventable complications during childbirth. Having delivered Marissa's 3rd child through cesarean section, Dr. Dela Cruz had prior knowledge of her medical history. Considering that her history and condition made her high-risk during delivery, potential life-threatening complications must have been anticipated and contingency measures must have been prepared to address these complications. Premature contractions, though not an unusual occurrence among pregnant patients, are not normal. The physician should have immediately realized the seriousness of the patient's condition because it is not normal to have premature contractions and bleeding at this stage of the pregnancy. The presence of these symptoms, when taken together with Marissa's medical history, should have alerted Dr. Dela Cruz. MEMCI’S LIABILITY Admittedly, Dr. Dela Cruz is just a consultant or guest doctor of MEMCI. Nevertheless, even if there is no employer-employee relationship between her and the hospital, this cannot automatically excuse the hospital from any liability. When the doctrine of apparent authority is adopted in medical negligence cases, "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."70 In the present case, though all prenatal check- ups of Marissa were conducted at the lying-in clinic of Dr. Dela Cruz outside MEMCI, the hospital impliedly held her out as a member of its medical staff by allowing her to use its facilities to treat her patients. Dr. Dela Cruz gave instructions to the nurse on duty of MEMCI and personally gathered the medical team for the procedures to be performed on Marissa. She even referred Marissa's condition to a urologist and cardiologist-internist while undergoing emergency cesarean section and hysterectomy. All these acts, when taken together, give the impression that she is a member of the medical staff of MEMCI. Thus, MEMCI cannot repudiate now this authority. De Jesus vs. Uyloan [ G.R. No. 234851. February 15, 2022 ] FACTS: De Jesus underwent an abdomino-pelvic sonogram. Dr. Uyloan diagnosed him with Cholelithiasis, a condition where there is a presence of stones in the gall bladder. Dr. Uyloan advised him to undergo laparoscopic cholecystectomy to remove the gallstones. The operation was done with Dr. Uyloan as attending physician and principal surgeon, and Dr. Ojeda as assisting surgeon. Dr. Uyloan and Dr. Ojeda performed an open cholecystectomy on petitioner without his approval or 24 Based on the lectures of Atty. Francis Talon, RN, MD ㎡ consent. During the operation in which his abdomen was opened up, he lost a lot of blood, which necessitated blood transfusion. Petitioner further alleged that upon his discharge from the AHMC, the release forms stated that he was in "good condition" and "recovered." However, he experienced vomiting and unbearable pain in his abdominal area, and there was continuous bile leak in his colostomy bag even after three days from discharge. During his follow-up checkup, Dr. Uyloan told him that the abdominal pains and bile leak were "part of it" and advised him to undergo magnetic resonance cholangio-pancreatography. Dissatisfied with Dr. Uyloan's response, petitioner went to another hospital for a series of medical tests, the results of which disclosed that instead of the cystic duct that joins the gall bladder to the common bile duct, it was the common bile duct that was cut and clipped. RULING: MEDICAL MALPRACTICE A mere reference to an implied contract between the physician and the patient in general is insufficient for pleading a cause of action under the contract theory of professional malpractice. An action for medical malpractice based on contract must allege an express promise to provide medical treatment or achieve a specific result. The following discussion of established rules on medical malpractice culled from fairly recent American jurisprudence highlights this point, viz.: Absent an express contract, a physician does not impliedly warrant the success of his or her treatment but only that he or she will adhere to the applicable standard of care. Thus, there is no cause of action for breach of implied contract or implied warranty arising from an alleged failure to provide adequate medical treatment. This allegation clea