Casumpang v. Cortejo Dr.

Casumpang simply nodded, inquired if Edmer

G.R. Nos. 171127, 171217, 17122 has an asthma, and reassured Mrs. Cortejo that
March 11, 2015 | Brion, J. | Gr 2 Gueco Edmer’s illness is bronchopneumonia.

Topic: 11:30AM  Edmer vomited "phlegm with blood

I. Negligence C. Standard of Conduct streak." Edmer’s father (respondent) requested for a
5. Experts c. Medical Professionals doctor at the nurses’ station. 45 minutes later, Dr.
Ruby Miranda-Sanga, one of the resident physicians
3 consolidated petitions against Nelson Cortejo of SJDH, arrived. Although she was aware that
Edmer had vomited "phlegm with blood streak," she
Facts failed to examine the blood specimen because the
April 22, 1988, 11:30AM  Mrs. Jesusa Cortejo respondent washed it away.
brought her 11 y/o son Edmer to the ER of the San
Juan de Dios Hospital (SJDH) because of difficulty Dr. Sanga conducted a physical check-up covering
in breathing, chest pain, stomach pain, and fever Edmer’s head, eyes, nose, throat, lungs, skin and
abdomen; and found that Edmer had a low-grade
Mrs. Cortejo’s testimony: non-continuing fever, and rashes that were not typical
 April 20 morning  Edmer developed a of dengue fever.
slight fever that lasted for a day. She
brought Edmer to the family doctor. 2 hours
3PM  Edmer vomited blood again. The respondent
after meds, his fever subsided.
showed Dr. Sanga Edmer’s blood specimen, and
 Dr. Ramoncito Livelo initially attended to
reported that Edmer complained of severe stomach
and examined Edmer. He took Edmer’s
pain and difficulty moving his right leg.
medical history, vital signs, body
temperature, blood pressure, & chest x-ray.
 He diagnosed Edmer with Dr. Sanga examined Edmer’s "sputum with blood"
“bronchopneumonia” and noted that he was bleeding. Suspecting that he
could have dengue, she inserted a plastic tube in his
 Edmer’s blood was also taken for testing,
nose, drained the liquid from his stomach with ice
typing, and for administering antibiotics. Dr.
cold normal saline solution, and gave an instruction
Livelo gave Edmer an antibiotic medication
not to pull out the tube, or give the patient any oral
to lessen his fever and loosen his phlegm
medication.
Mrs. Cortejo did not know any doctor at SJDH. She
used her Fortune Care card and was assigned to Dr. Dr. Sanga conducted a tourniquet test: negative. She
Noel Casumpang, a pediatrician accredited with also ordered the monitoring of the patient’s blood
Fortune Care. pressure and some blood tests. Normal.

5:30PM  Dr. Casumpang examined Edmer for the 4:40 PM  Dr. Sanga called Dr. Casumpang and
first time. Using only a stethoscope, he confirmed the told him about Edmer’s condition. Dr. Casumpang
initial diagnosis of “Bronchopneumonia” ordered several procedures done. Dr. Sanga advised
Edmer’s parents that the blood test results showed
Mrs. Cortejo recalled entertaining doubts on the that he had "Dengue Hemorrhagic Fever."
doctor’s diagnosis. She immediately advised Dr.
Casumpang that Edmer had a high fever, and had no One hour later, Dr. Casumpang arrived at Edmer’s
colds or cough. Dr. Casumpang told her that Edmer’s room and he recommended his transfer to the ICU,
"blood pressure is just being active," and "that’s the however it was full, so Dr. Casumpang suggested that
usual bronchopneumonia, no colds, no phlegm." they hire a private nurse. Respondent insisted on
transferring Edmer to Makati Medical Center
April 23, 9AM  Dr. Casumpang examined Edmer.
Mrs. Cortejo again called his attention and stated that After the respondent signed the waiver, Dr.
Edmer had a fever, throat irritation, and chest and Casumpang checked Edmer’s condition, found that
stomach pain. Mrs. Cortejo also alerted Dr. his blood pressure was stable, and noted that he was
Casumpang about the traces of blood in Edmer’s "comfortable." The respondent requested for an
sputum. ambulance but the driver couldn’t be found. This
prompted him to hire a private ambulance for  Dr. Jaudian is not a qualified expert
₱600.00.
3. SJDH
12:00 MN  Edmer was transferred to Makati  Petitioners are mere independent contractors
Medical Center. Dr. Casumpang immediately gave and consultants (not employees) of the
the attending physician the patient’s clinical history hospital; no employer-employee
and laboratory exam results. The attending physician relationship; Art 2180 does not apply
diagnosed "Dengue Fever Stage IV" that was already  Even if they are considered employees,
in its irreversible stage. SJDH cannot still be held solidarily liable
because of: (1) the adequate measures that
April 24, 1988, 4AM  Edmer died. His Death the hospital undertakes to ascertain the
Certificate indicated the cause as "Hypovolemic petitioning doctors’ qualifications and
Shock/hemorrhagic shock;" "Dengue Hemorrhagic medical competence, and (2) the
Fever Stage IV." documentary evidence that the petitioning
doctors presented to prove their competence
in the field of pediatrics
Believing that Edmer’s death was caused by the
negligent and erroneous diagnosis of his doctors, the
Issues + Ruling
respondent instituted an action for damages against
1. Whether or not the petitioning doctors had
SJDH, and its attending physicians: Dr. Casumpang
committed "inexcusable lack of precaution" in
and Dr. Sanga before the RTC of Makati City.
diagnosing and in treating the patient;
- Dr. Casumpang YES; Dr. Sanga NO
RTC: ruled in favor of respondent; awarded actual
and moral damages + atty’s fees and costs This is a medical malpractice suit, an action available
to victims to redress a wrong committed by medical
CA: affirmed RTC’s ruling professionals who caused bodily harm to, or the death
of, a patient.
The Petitions (contentions of the doctors)
Dr. Casumpang To successfully pursue a medical malpractice suit,
 He gave Edmer medical treatment and care the plaintiff must prove that the doctor either failed to
to the best of his abilities and within the do what a reasonably prudent doctor would have
proper standard of care required from done, or did what a reasonably prudent doctor would
physicians under similar circumstances not have done; and the act or omission had caused
 His initial diagnosis of bronchopneumonia injury to the patient. The patient’s heir/s bear the
was supported by the chest x-ray result burden of proving his/her cause of action
 Dengue fever occurs only after several days
of confinement; when he suspected that Elements of a Medical Malpractice Suit: (1) duty,
Edmer might have dengue, he immediately (2) breach, (3) injury, (4) proximate causation
treated him
 Raised doubts on Dr. Jaudian’s credibility Duty  the standard of behavior that imposes
restrictions on one’s conduct; it requires proof of
Dr. Sanga professional relationship bet physician & patient
 Function of making diagnosis and
undertaking the medical treatment devolved A physician-patient relationship is created when a
upon Dr. Casumpang, who confirmed patient engages the services of a physician, and the
“bronchopneumonia” latter accepts/agrees to provide care to the patient
 She exercised prudence in performing her  Consent need not be express; may be
duties as physician implied from physician’s affirmative action
 It was her professional intervention that led to diagnose/treat a patient
to the correct diagnosis of “Dengue  Once a physician-patient relationship is
Hemorrhagic Fever” established, the legal duty of care follows
 No causal relation bet alleged erroneous  Breach of duty occurs when the doctor fails
diagnosis & medication for to comply with or improperly performs his
bronchopneumonia & Edmer’s death due to duties under professional standards
dengue hemorrhagic fever
To successfully claim damages, the patient must During his first two visits to Edmer, he already had
prove the causal relation between the negligence and knowledge of Edmer’s laboratory test result, medical
the injury. This connection must be direct, natural, history, and symptoms. Nonetheless, he already ruled
and should be unbroken by any intervening efficient out the possibility of other diseases like dengue. He
causes. (Must be proximate cause) selectively appreciated some, and not all of the
symptoms; worse, he casually ignored the pieces of
Both Dr. Casumpang and Dr. Sanga have a information that could have been material in
physician-patient relationship with Edmer. detecting dengue fever.

Jarcia Jr v People of the PH  doctors who merely Dr. Casumpang did not even bother to check Edmer’s
passed by and were requested to attend to the patient throat despite knowing that as early as 9AM on April
are liable for medical malpractice; the relationship 23 that Edmer had blood streaks in his sputum.
was established when they examined the patient, and
later assured the mother that everything was fine Dr. Jaudian: Dr. Casumpang’s medical examination
was not comprehensive enough to reasonably lead to
In the present case, expert testimony is crucial in
a correct diagnosis. He only used a stethoscope in
determining: (1) the standard medical examinations,
diagnosing bronchopneumonia. He based his
tests, and procedures that the attending physicians
diagnosis largely on the chest x-ray result that is
should have undertaken in the diagnosis and
generally inconclusive.
treatment of dengue fever (2) dengue fever signs and
symptoms that the attending physicians should have
noticed and considered. It was only after Edmer’s third episode of bleeding
that he ordered the conduct of hematocrit,
hemoglobin, blood typing, blood transfusion and
RTC & CA relied largely on Dr. Jaudian’s expert
tourniquet tests. These tests came too late.
testimony on dengue diagnosis and management to
support their finding that the petitioning doctors were
guilty of breach of duty of care. A wrong diagnosis is not by itself medical
malpractice. Physicians are generally not liable for
damages resulting from a bona fide error of
Dr. Jaudian testified that Edmer’s rapid breathing, judgment. Nonetheless, when the physician’s
chest and stomach pain, fever, and the presence of erroneous diagnosis was the result of negligent
blood in his saliva are classic symptoms of dengue
conduct, it becomes an evidence of medical
fever. If the patient was admitted for chest pain,
malpractice.
abdominal pain, and difficulty in breathing coupled
with fever, dengue fever should definitely be
considered; if the patient spits coffee ground with the Medicine is not an exact science. Error is possible as
presence of blood, and the patient’s platelet count the exercise of judgment is called for in considering
drops to 47,000, it becomes a clear case of dengue and reading the exhibited symptoms, the results of
fever, and bronchopneumonia can be ruled out. tests, and in arriving at definitive conclusions. But in
doing all these, the doctor must have acted according
The standard of care according to Dr. Jaudian is to to acceptable medical practice standards.
administer oxygen inhalation, analgesic, and fluid
infusion or dextrose. If the patient had twice vomited Dr. Casumpang failed to timely detect dengue fever,
fresh blood and thrombocytopenia has already which failure, especially when reasonable prudence
occurred, the doctor should order blood transfusion, would have shown that indications of dengue were
monitoring of the patient every 30 minutes, evident and/or foreseeable, constitutes negligence.
hemostatic to stop bleeding, and oxygen if there is
difficulty in breathing. Apart from failing to promptly detect dengue fever,
Dr. Casumpang also failed to promptly undertake the
Dr. Casumpang proper medical management needed for this disease.
At the trial, he declared that a doctor’s impression
regarding a patient’s illness is 90% based on the Dr. Sanga (junior resident physician)
physical examination, the info given by the
patient/parents, and the patient’s medical history
Resident physicians  function under the
supervision of attending physicians or of the
hospital’s teaching staff.
Attending physician  primarily responsible for control not only the end to be achieved, but the
managing the resident’s exercise of duties. means to be used in reaching such an end.

The standards applicable to and the liability of the Control (crucial) is not present. No evidence showing
resident for medical malpractice is theoretically less that SJDH exercised any degree of control over the
than that of the attending physician. means, methods of procedure and manner by which
the petitioning doctors conducted and performed their
Jenkins v. Clark  the applicable standard of care in medical profession. Thus, the petitioning doctors
medical malpractice cases involving first-year were mere independent contractors.
residents was that of a reasonably prudent physician
and not that of interns. Nonetheless, SJDH is not free from liability. As a
Centman v. Cobb  interns and first-year residents rule, hospitals are not liable for the negligence of its
are "practitioners of medicine required to exercise the independent contractors. However, it may be found
same standard of care applicable to physicians with liable if the physician or independent contractor acts
unlimited licenses to practice." as an ostensible agent of the hospital. This exception
is also known as the "doctrine of apparent authority."
Dr. Sanga was not independently negligent. Although
she had greater patient exposure & was subject to the Gilbert v. Sycamore Municipal Hospital  hospitals
same standard of care as attending physicians, a could be found vicariously liable for the negligence
finding of negligence should also depend on several of an independent contractor.
factors, like her authority to make her own diagnosis, Nogales v. Capitol Medical Center  two factors in
the degree of supervision of the attending physician determining hospital liability: (1) the hospital’s
over her, and the shared responsibility between her & manifestations (2) the patient’s reliance.
the attending physicians.
SJDH impliedly clothed Dr. Casumpang with
Before Dr. Sanga attended to Edmer, both Dr. Livelo apparent authority leading the respondent to believe
and Dr. Casumpang had diagnosed Edmer with that he is an employee of the hospital. Mrs. Cortejo
bronchopneumonia. Dr. Sanga likewise duly reported accepted Dr. Casumpang’s services on the reasonable
to Dr. Casumpang. There is also evidence that she belief that such were being provided by SJDH .
extended diligent care to Edmer.
3. Whether or not there is a causal connection
Her failure to discern the import of Edmer’s second between the petitioners’ negligent act/omission
bleeding does not necessarily amount to negligence and the patient’s resulting death
as the respondent himself admitted that Dr. Sanga YES
failed to examine the blood specimen because he
washed it away. Considering the diagnosis previously Dr. Casumpang failed to timely diagnose Edmer with
made by two doctors, and the uncontroverted fact that dengue fever despite the presence of its characteristic
the burden of final diagnosis pertains to the attending symptoms; and as a consequence of the delayed
physician, Dr. Sanga’s error was merely an honest diagnosis, he also failed to promptly manage Edmer’s
mistake of judgment influenced in no small measure illness. Had he immediately conducted confirmatory
by her status in the hospital hierarchy. tests and promptly administered the proper care and
management needed for dengue fever, the risk of
2. Whether or not the petitioner hospital is complications or even death, could have been
solidarily liable with the petitioning doctors substantially reduced.
YES
Medical literature on dengue shows that early
We affirm the hospital’s liability not on the basis of diagnosis and management of dengue is critical in
Article 2180 of the Civil Code, but on the basis of the reducing the risk of complications and avoiding
doctrine of apparent authority or agency by estoppel. further spread of the virus. That Edmer later died of
"Hypovolemic Shock/hemorrhagic shock," "Dengue
In determining whether an employer-employee Hemorrhagic Fever Stage IV," a severe and fatal
relationship exists between the parties, the following form of dengue fever, established the causal link
elements must be present: (1) selection and between Dr. Casumpang’s negligence and the injury.
engagement of services; (2) payment of wages; (3)
the power to hire and fire; and (4) the power to
4. Whether or not the lower courts erred in
considering Dr. Rodolfo Tabangcora Jaudian as
an expert witness.

Dr. Jaudian was not a pediatrician but a practicing

physician who specializes in pathology. He likewise
does not possess any formal residency training in
pediatrics. Nonetheless, both lower courts & SC
found his knowledge acquired through study and
practical experience sufficient to advance an expert
opinion on dengue-related cases.

To qualify a witness as a medical expert, it must be

shown that the witness (1) has the required
professional knowledge, learning and skill of the
subject under inquiry sufficient to qualify him to
speak with authority on the subject; and (2) is
familiar with the standard required of a physician
under similar circumstances; where a witness has
disclosed sufficient knowledge of the subject to
entitle his opinion to go to the jury, the question of
the degree of his knowledge goes more to the weight
of the evidence than to its admissibility.

The general rule as to expert testimony in medical

malpractice actions is that "a specialist in a particular
branch within a profession will not be required."
Most courts allow a doctor to testify if they are
satisfied of his familiarity with the standards of a
specialty, though he may not practice the specialty
himself. It is the scope of the witness’ knowledge and
not the artificial classification by title that should
govern the threshold question of admissibility.

Dr. Jaudian is competent to testify on the standard of

care in dengue fever cases. Although he specializes in
pathology, it was established during trial that he had
attended not less than 30 seminars held by the
Pediatric Society, had exposure in pediatrics, had
been practicing medicine for 16 years, and had
handled not less than 50 dengue related cases.

Mrs. Cortejo’s use Fortune Care did not affect

SJDH’s liability. The only effect of the availment of
her Fortune Care card benefits is that her choice of
physician is limited only to physicians who are
accredited with Fortune Care.