1

MEDICAL MALPRACTICE:
In the Philippines, there is no such thing as Medical Malpractice Law. No single law to make
physicians liable for medical malpractice.
ELEMENTS THAT HAVE TO PROVEN IN COURT THAT THERE IS MEDICAL NEGLIGENCE
Whoever alleges a fact has the burden of proving it. This is a basic legal principle that equally applies
to civil and criminal cases. In a medical malpractice case, the plaintiff has the duty of proving its
elements, namely: (1) a duty of the defendant to his patient; (2) the defendant’s breach of this duty
(thru the presentation of expert witness at least belonging to the same field of specialty and preferably
in the same locality, to establish the standard of care); (3) injury to the patient; and (4) proximate
causation between the breach and the injury suffered. 17 In civil cases, the plaintiff must prove these
elements by a preponderance of evidence.
(Except when the pathologist has proven that he has sufficient knowledge on dengue cases, because
before he became a pathologist, he has been a physical experienced on dengue cases.)
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. 21

EXCEPTION TO THE RULE (of presenting expert witness): EVEN WITHOUT THE TESTIMONY OF
AN EXPERT WITNESS, THE COURT CAN DETERMINE THE CAUSE OF INJURY (COMMON
KNOWLEDGE OR EXPERIENCE)
DOCTRINE OF RES IPSA LOCITUR: the injury is so gross that it can equate to evidence already
The application of this rule requires: (1) that the accident was of a kind which does not ordinarily
occur unless someone is negligent; (2) that the instrumentality or agency which caused the injury was
under the exclusive control of the person charged with negligence; and (3) that the injury suffered
must not have been due to any voluntary action or contribution from the injured person.
The requisites for the applicability of the doctrine of res ipsa loquitur are: (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
This doctrine is used in conjunction with the doctrine of common knowledge. We have applied this
doctrine in the following cases involving medical practitioners:
a. Where a patient who was scheduled for a cholecystectomy (removal of gall stones) but was
otherwise healthy suffered irreparable brain damage after being administered anesthesia prior
to the operation.39
b. Where after giving birth, a woman woke up with a gaping burn wound close to her left
armpit;40
c. The removal of the wrong body part during the operation; and
d. Where an operating surgeon left a foreign object (i.e., rubber gloves) inside the body of the
patient.41
UNDER RAMOS CASE, THE COURT MADE A PRONOUNCEMENT THAT DOCTORS ARE
NOT LIABLE UNDER VICARIOUS LIABILITY (ART.2180),
BUT UNDER AGANA CASE, (1) UNDER DOCTRINE OF AGENCY, DOCTORS ARE LIABLE
UNDER APPARENT AUTHORITY OR OSTENSIBLE AGENCY OR ESTOPPEL, ALTHOUGH
THERE IS NO EMPLOYER-EMPLOYEE RELATIONSHIP. DOCTORS CAN ALSO BE HELD
LIABLE UNDER (2) CORPORATE NEGLIGENCE (when a company enters into a contractual
relationship, it is responsible to ensure the safety of the patients within its premises, and that
the doctors are competent in handling the patients).
 2

G.R. No. 124354 RAMOS (1999) v. CA 321 SCRA 584

FACTS: Plaintiff Erlinda Ramos was experiencing occasional pains allegedly caused by stones in her
gall bladder. She was told to undergo an operation and after some tests and exams, she was
indicated fit for surgery.

Dr. Orlino Hozaka, defendant, decided that Erlinda should undergo a “cholecystectomy” operation.
Rogelio, husband of Erlinda, asked Dr. Hosaka to look for a good anesthesiologist.

Around 7:30 AM of June 17, 1985, Herminda (sister-in-law of Erlinda) accompanied Erlinda to the
operating room and saw Dr. Gutierrez, the other defendant, who was to administer anesthesia. Dr.
Hosaka only arrived around 12:15 PM, three hours late. Nonetheless, the operation continued and
Herminda then saw Dr. Gutierrez intubating the patient and heard her saying “and hirap ma-intubate
nito, mali yata ang pagkakapasok”. Thereafter, bluish discoloration of the nailbeds appeared on the
patient. Hence, Dr. Hosaka issued an order for someone to call Dr. Calderon, another
anesthesiologist. The patient was placed in a trendelenburg position for decrease of blood supply in
her brain. At 3:00 PM, the patient was taken to the ICU.

Four months after, the patient was released from the hospital. However, the patient has been in a
comatose condition.

Hence, the petition filed a civil case for damages against herein private respondents alleging
negligence in the management and care of Erlinda Ramos.

Petitioners contended that the faulty management of her airway caused the lack of oxygen in the
patient’s brain. On the respondent’s part, they contended that the brain damage was Erlinda's allergic
reaction to the anesthetic agent.

ISSUES: (1) Will the doctrine of res ipsa loquitur apply in this case? and (2) Did the negligence of the
respondents cause the unfortunate comatose condition of petitioner Erlinda Ramos? Res ipsa
loquitur means that because the facts are so obvious, a party need not explain any more.

RULING: (1) Yes. The Court finds the doctrine of res ipsa loquitur appropriate in the case at bar.

The doctrine of res ipsa loquitur is where the thing which caused the injury complained of is shown to
be under the management of the defendant or his servants and the accident is such as in ordinary
course of things does not happen if those who have its management or control use proper care , it
affords reasonable evidence, in the absence of explanation by the defendant, that the accident arose
from or was caused by the defendant's want of care.

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.

Erlinda submitted herself soundly and fit for surgery. However, during the administration of
anesthesia and prior to the performance of cholecystectomy she suffered irreparable damage to her
brain. Thus, without undergoing surgery, she went out of the operating room already decerebrate and
 3

totally incapacitated. Obviously, brain damage, which Erlinda sustained, is an injury which does not
normally occur in the process of a gall bladder operation.

Considering that a sound and unaffected member of the body (the brain) is injured or destroyed while
the patient is unconscious and under the immediate and exclusive control of the physicians, we hold
that a practical administration of justice dictates the application of res ipsa loquitur.

(2a) With regard to Dra. Gutierrez, the court find her negligent during the anesthesia phase. As borne
by the records, respondent Dra. Gutierrez failed to properly intubate the patient which she admitted.

During intubation, such distention indicates that air has entered the gastrointestinal tract through the
esophagus instead of the lungs through the trachea. Entry into the esophagus would certainly cause
some delay in oxygen delivery into the lungs as the tube which carries oxygen is in the wrong place.

Even granting that the tube was successfully inserted during the second attempt, it was obviously too
late.

An experienced anesthesiologist, adequately alerted by a thorough pre-operative evaluation, would

have had little difficulty going around the short neck and protruding teeth.

Hence, she was negligent.

(2b) For Dr. Orlino Hosaka, as the head of the surgical team and as the so-called captain of the ship,
it is the surgeons responsibility to see to it that those under him perform their task in the proper
manner

Respondent Dr. Hosakas negligence can be found in his failure to exercise the proper authority (as
the captain of the operative team) in not determining if his anesthesiologist observed proper
anesthesia protocols. In fact, no evidence on record exists to show that respondent Dr. Hosaka
verified if respondent Dra. Gutierrez properly intubated the patient. Furthermore, it does not escape
the court that respondent Dr. Hosaka had scheduled another procedure in a different hospital at the
same time as Erlinda's operation, and was in fact over three hours late for the latter's operation.
Because of this, he had little or no time to confer with his anesthesiologist regarding the anesthesia
delivery. This indicates that he was remiss in his professional duties towards his patient.

Thus, he shares equal responsibility for the events which resulted in Erlindas condition.

(2c) As for the hospital (employer) itself, the Court ruled that for the purpose of allocating
responsibility in medical negligence cases, an employer-employee relationship in effect exists
between hospitals and their attending and visiting physicians.

In the instant case, respondent hospital, apart from a general denial of its responsibility over
respondent physicians, failed to adduce evidence showing that it exercised the diligence of a good
father of a family in the hiring and supervision of the latter. It failed to adduce evidence with regard to
the degree of supervision which it exercised over its physicians. In neglecting to offer such proof, or
proof of a similar nature, respondent hospital thereby failed to discharge its burden under the last
paragraph of Article 2180.

Having failed to do this, respondent hospital is consequently solidarily responsible with its physicians
for Erlindas condition.
 4

CARLOSBORROMEO, Petitioner, vs.
FAMILY CARE HOSPITAL, INC. and RAMON S. INSO, M.D., Respondents.

ANTECEDENTS
The petitioner, Carlos Borromeo, was the husband of the late Lilian V. Borromeo (Lilian). Lilian was a
patient of the respondent Family Care Hospital, Inc. (Family Care) under the care of respondent Dr.
Ramon Inso (Dr. Inso).
On July 13, 1999, the petitioner brought his wife to the Family Care Hospital because she had been
complaining of acute pain at the lower stomach area and fever for two days. She was admitted at the
hospital and placed under the care of Dr. 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. Thus, he
ordered Lilian’s confinement for testing and evaluation.
Over the next 48 hours, Lilian underwent multiple tests such as complete blood count, urinalysis,
stool exam, pelvic ultrasound, and a pregnancy test. However, the tests were not conclusive enough
to confirm that she had appendicitis.
Meanwhile, Lilian’s condition did not improve. She suffered from spiking fever and her abdominal pain
worsened. The increasing tenderness of her stomach, which was previously confined to her lower
right side, had also extended to her lower left side. Lilian abruptly developed an  acute surgical
abdomen.
On July 15, 1999, 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. Exploratory
laparotomy is a surgical procedure involving a large incision on the abdominal wall that would enable
Dr. Inso to examine the abdominal cavity and identify the cause of Lilian’s symptoms. After explaining
the situation, Dr. Inso obtained the patient’s consent to the laparotomy.
At around 3:45 P.M., Lilian was brought to the operating room where Dr. Inso conducted the surgery.
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. Lilian’s appearance and vital signs improved. At around 7:30 P.M.,
Lilian was brought back to her private room from the recovery room.
At around 1:30 A.M. on July 16, 1999, roughly six hours after Lilian was brought back to her room, Dr.
Inso was informed that her blood pressure was low. After assessing her condition, he ordered the
infusion of more intravenous (IV) fluids which somehow raised her blood pressure.
Despite the late hour, Dr. Inso remained in the hospital to monitor Lilian’s condition. Subsequently, a
nurse informed him that Lilian was becoming restless. Dr. Inso immediately went to Lilian and saw
that she was quite pale. He immediately requested a blood transfusion.
Lilian did not respond to the blood transfusion even after receiving two 500 cc-units of blood. Various
drugs, such as adrenaline or epinephrine, were administered.
Eventually, an endotracheal tube connected to an oxygen tank was inserted into Lilian to ensure her
airway was clear and to compensate for the lack of circulating oxygen in her body from the loss of red
blood cells. Nevertheless, her condition continued to deteriorate.
Dr. Inso observed that Lilian was developing petechiae in various parts of her body. Petechiae are
small bruises caused by bleeding under the skin whose presence indicates a blood-coagulation
problem – a defect in the ability of blood to clot. 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.
 5

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 cardiopulmonary resuscitation (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 Department of Health to have one. Dr. Inso informed
the petitioner that Lilian would have to be transferred to another hospital.
At around 3:30 A.M., Dr. Inso personally called the Perpetual Help Medical Center to arrange Lilian’s
transfer, but the latter had no available bed in its ICU. Dr. Inso then personally coordinated with the
Muntinlupa Medical Center (MMC) which had an available bed.
At around 4:00 A.M., Lilian was taken to the MMC by ambulance accompanied by the resident doctor
on duty and a nurse. Dr. Inso followed closely behind in his own vehicle.
Upon reaching the MMC, a medical team was on hand to resuscitate Lilian. A nasogastric tube (NGT)
was inserted and IV fluids were immediately administered to her. Dr. Inso asked for a plasma
expander. Unfortunately, at around 10:00 A.M., Lilian passed away despite efforts to resuscitate her.

Dr. Reyes concluded that the cause of Lilian’s death was hemorrhage due to bleeding petechial blood
vessels: internal bleeding. He further concluded that the internal bleeding was caused by the 0.5 x 0.5
cm opening in the repair site. He opined that the bleeding could have been avoided if the site was
repaired with double suturing instead of the single continuous suture repair that he found.
Based on the autopsy, the petitioner filed a complaint for damages against Family Care and against
Dr. Inso for medical negligence.
During the trial, the petitioner presented Dr. Reyes as his expert witness. Dr. Reyes testified as to his
findings during the autopsy and his opinion that Lilian’s death could have been avoided if Dr. Inso had
repaired the site with double suture rather than a single suture.
However, Dr. Reyes admitted that he had very little experience in the field of pathology and his only
experience was an on-the-job training at the V. Luna Hospital where he was only on observer status.
He further admitted that he had no experience in appendicitis or appendectomy and that Lilian’s case
was his first autopsy involving a death from appendectomy.
ISSUE:
WHETHER OR NOT THE RESPONDENTS ARE GUILTY OF MEDICAL NEGLIGENCE. (NO)
RULING:

Whoever alleges a fact has the burden of proving it. This is a basic legal principle that equally applies
to civil and criminal cases. In a medical malpractice case, the plaintiff has the duty of proving its
elements, namely: (1) a duty of the defendant to his patient; (2) the defendant’s breach of this duty;
(3) injury to the patient; and (4) proximate causation between the breach and the injury suffered. 17 In
civil cases, the plaintiff must prove these elements by a preponderance of evidence.
A medical professional has the duty to observe the standard of care and exercise the degree of skill,
knowledge, and training ordinarily expected of other similarly trained medical professionals acting
under the same circumstances.18 A breach of the accepted standard of care constitutes negligence or
malpractice and renders the defendant liable for the resulting injury to his patient. 19
The standard is based on the norm observed by other reasonably competent members of the
profession practicing the same field of medicine.20 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.21
 6

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 22 and an autopsy
expert is not qualified to testify as a specialist in infectious diseases. 23
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/conditions that might or might not have
caused or contributed to Lilian’s death.
The testimony of Dr. Avila also has no probative value in determining whether Dr. Inso was at fault.
Dr. Avila testified in his capacity as an expert in medical jurisprudence, not as an expert in medicine,
surgery, or pathology. His testimony fails to shed any light on the actual cause of Lilian’s death.
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 application of this rule requires: (1) that the accident was of a kind which does not ordinarily
occur unless someone is negligent; (2) that the instrumentality or agency which caused the injury was
under the exclusive control of the person charged with negligence; and (3) that the injury suffered
must not have been due to any voluntary action or contribution from the injured person.38 The
concurrence of these elements creates a presumption of negligence that, if unrebutted, overcomes
the plaintiff’s burden of proof.
This doctrine is used in conjunction with the doctrine of common knowledge. We have applied this
doctrine in the following cases involving medical practitioners:
a. Where a patient who was scheduled for a cholecystectomy (removal of gall stones) but was
otherwise healthy suffered irreparable brain damage after being administered anesthesia prior
to the operation.39
b. Where after giving birth, a woman woke up with a gaping burn wound close to her left
armpit;40
c. The removal of the wrong body part during the operation; and
d. Where an operating surgeon left a foreign object (i.e., rubber gloves) inside the body of the
patient.41
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. 42 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. 43

DR. NOEL CASUMPANG vs. CORTEJO G.R. No. 171127

March 11, 2015
BRION, J.:
STATEMENT OF FACTS:
Edmer Cortejo (Edmer) was brought to the emergency room of San Juan de Dios Hospital
(SJDH) by his mother, Mrs. Jesusa Cortejo (Jesusa) due to difficulty in breathing, chest pains,
stomach pain, and fever. Dr. Ramoncito Livelo (Livelo), a family doctor, initially attended to Edmer
and after a few tests had the initial impression of Bronchopneumonia. Dr. Livelo then gave Edmer
some antibiotics to lessen his fever and loosen his phlegm.
Jesusa did not know anyone from SJDH. Jesusa used her fortune card and was referred to a Fortune
Care Coordinator, who was then absent. She got assigned to Dr. Noel Casumpang (Casumpang)
who appeared to be an employee of the hospital. Dr. Casumpang examined Edmer for the first time
 7

and merely used a stethoscope and determined that it was Bronchopneumonia. Not satisfied, she
stated that Edmer had high fever, no colds or cough; Dr. Casumpang that it was normal for
Bronchopneumonia. The following day early morning, Edmer had now a fever, throat irritation and
even stomach and chest pains. Despite being known to such information, Dr. Casumpang mere
inquired if Edmer had asthma, reassured that the illness was Bronchopneumonia.
Later in the morning, Edmer began vomiting phlegm with blood streak. Nelson Cortejo (Nelson),
Edmers father, thus called for a doctor and Dr. Ruby Miranda-Sanga (Sanga) came to their call. Dr.
Sanga examined Edmer and found that he had a low grade non continuing fever, rashes that were
not typical of dengue fever. Dr. Rubi had told Dr. Casumpang of the symptoms.
She failed to positively diagnose the patient immediately because the blood streak was washed by
the Nelson, thus she ordered the next time it occurred Nelson should preserve the same. Upon
acquiring a sample she positively determined that it was Dengue Hemorrahgic Fever. Dr.
Casumpang advised that Edmer be bought to the ICU, to which the spouses Cortejo agreed to but
the ICU was full, thus they opted to go to Makati Medical Center. Upon arriving it was declared that it
was already at stage IV and thus irreversible. Edmer died.
STATEMENT OF THE CASE:
Nelson instituted an action for damages against Dr. Casumpang, Dr. Sanga, SJDH before the RTC of
Makati City for the negligent and erroneous diagnosis of his doctors. RTC ruled in favor of Nelson and
deemed Drs. Casumpang and Sanga liable since Dengue was foreseeable based on the medical
record of Edmer, and that their testimonies were self-serving providing no other evidence. The CA
affirmed the decision of the RTC in toto, hence this petition.

PETITIONERS DEFENSES:
1. DR. CASUMPANG : GAVE EDMER MEDICAL TREATMENT ACCDG. TO THE BEST OF
HIS
ABILITIES; DENGUE FEVER ONLY OCCURS AFTER SEVERAL DAYS OF
CONFINEMENT; DR.
JAUDIAN, CREDIBLE?
2. DR. MIRANDA : DR. CASUMPANG WAS THE DOCTOR ASSIGNED; SHE EXERCISED
PRUDENCE;
NO CAUSAL REL. BETWEEN THE INITIAL DIAGNOSIS TO THE CAUSE OF DEATH; DR.
JAUDIAN ALSO NOT CREDIBLENO EVIDENCE OF CERT. OF FORMAL RESIDENCY OR
FELLOWSHIP IN PEDIATRICS
3. SJDH : DR. CASUMPANG AND DR. MIRANDA ARE MERE INDEPENDENT
CONTRACTTORS; NO EER; THEY DON’T HIRE CONSULTANTS, ONLY GRANT
PRIVILEGES TOWARDS THEM; DON’T PAY THEM WAGES; NO POWER OF CONTROL:
OBSERVED PROPER DILIGENCE OF A GOOD FATHER OF THE FAMILY
4. RESPONDENTS: THEY RAISE FACTUAL ISSUES, NOT REVIEWABLE BY THIS COURT;
THE DOCTORS WERE NEGLIGENTFAILED TO TIMELY DIAGNOSE, THEIR MEDICAL
EXAMINATION WAS NOT COMPREHENSIVE, EMPLOYED A GUESSING GAME; SDJH
HAS NO PROPER PAGING SYSTEM, NO BRONCHOSOPE, RATIO OF DOCTORS TO
PATIENTS LOW
ISSUES:
death.
1.) Only Dr. Casumapang was negligent; Dr. Sanga was not DR. CASUMPANG WAS NEGLIGENT
IN DIAGNOSIS:
HELD:
1.) Whether Drs. Casumpang and Sanga committed inexcusable lack of precaution in diagnosing and
in treating the patient
 8

2.) Whether SJDH is solidarily liable with the doctors

3.) Whether there is a causal connection between the doctor’s negligence and the patient’s
It will be recalled that during Dr. Casumpang's
first and second visits to Edmer, he already had knowledge of Edmer's laboratory test result (CBC),
medical history, and symptoms (i.e., fever, rashes, rapid breathing, chest and stomach pain, throat
irritation, difficulty in breathing, and traces of blood in the sputum). However, these information did
not lead Dr. Casumpang to the possibility that Edmer could be suffering from either dengue
fever, or dengue hemorrhagic fever, as he clung to his diagnosis of broncho pneumonia. This
means that given the symptoms exhibited, Dr. Casumpang already ruled out the possibility of other
diseases like dengue.
In other words, it was lost on Dr. Casumpang that the characteristic symptoms of dengue (as Dr.
Jaudian testified) are: patient's rapid breathing; chest and stomach pain; fever; and the presence of

blood in his saliva. He was selective in appreciating the symptoms.

DR. CASUMPANG WAS NEGLIGENT IN THE TREATMENT AND MANAGEMENT OF DENGUE:
Dr.
DR. MIRANDA IS NOT LIABLE FOR NEGLIGENCE:
Casumpang failed to measure up to these standards. The evidence strongly suggests that he ordered
a transfusion of platelet concentrate instead of blood transfusion. The tourniquet test was only
conducted after Edmer's second episode of bleeding, and the medical management (as reflected in
the records) did not include antibiotic therapy and complete physical examinationNO ANTIBIOTIC
THERAPY AND COMPLETE PHY. EXAMINATION
careful physicians or hospital emergency room operators, not of interns or residents; 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; Dr. Miranda likewise duly reported to Dr. Casumpang, who admitted receiving updates
regarding Edmer's condition. There is also evidence supporting Dr. Miranda'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
the medical care required is that of reasonably
assistance led to the finding of dengue fever.
2. YES, under the doctrine of vicarious liability (apparent authority).
SJDH’S LIABILITY BASED ON THE DOCTRINE OF APPARENT AUTHORITY NOT
RESPONDEAT SUPERIOR
We hold that, 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.
The doctrine of apparent authority, a plaintiff must show that:
(1) the hospital, or its agent, acted in a manner that would lead a reasonable person to conclude that
the individual who was alleged to be negligent was an employee or agent of the hospital;
(2) where the acts of the agent create the appearance of authority, the plaintiff must also prove that
the hospital had knowledge of and acquiesced in them; and

(3) the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent
with ordinary care and prudence. (Emphasis supplied)
 9

The first factor focuses on the hospital’s manifestations and is sometimes described as an inquiry
whether the hospital acted in a manner which would lead a reasonable person to conclude that the
individual who was alleged to be negligent was an employee or agent of the hospital. In this regard,
the hospital need not make express representations to the patient that the treating physician is an
employee of the hospital; rather a representation may be general and implied.

The second factor focuses on the patient's reliance. It is 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. (Citation omitted)

1. HOSPITAL’S MANIFESTATIONS:
2. PATIENT’S RELIANCE: SDJH CLOTHED DR. CASUMPANG W/ APPARENT AUTHORITY
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.
Based on the records, the respondent relied on SJDH rather than upon Dr. Casumpang, to care and
treat his son Edmer. His testimony during trial showed that he and his wife did not know any doctors
at SJDH;they also did not know that Dr. Casumpang was an independent contractor. They
brought their son to SJDH for diagnosis because of their family doctor's referral. The referral did not
specifically point to Dr. Casumpang or even to Dr. Miranda, but to SJDH.
Significantly, the respondent had relied on SJDH's representation of Dr. Casumpang's authority. To
recall, when Mrs. Cortejo presented her Fortune Care card, she was initially referred to the Fortune
Care coordinator, who was then out of town. She was thereafter referred to Dr. Casumpang, who is
also accredited with Fortune Care. In both instances, SJDH through its agent failed to advise Mrs.
Cortejo that Dr. Casumpang is an independent contractor.
Mrs. Cortejo accepted Dr. Casumpang's services on the reasonable belief that such were being
provided by SJDH or its employees, agents, or servants. By referring Dr. Casumpang to care and
treat for Edmer, SJDH impliedly held out Dr. Casumpang, not only as an accredited member of
Fortune Care, but also as a member of its medical staff.

Professional Services Inc. (PSI) v. Agana, G.R. No. 126297, 31 January 2007.

FACTS:
Natividad Agana was rushed to the Medical City General Hospital (Medical City Hospital) because of
difficulty of bowel movement and bloody anal discharge. After a series of medical examinations, Dr.
Miguel Ampil diagnosed her to be suffering from “cancer of the sigmoid.” Dr. Ampil, assisted by the
medical staff of the Medical City Hospital, performed an anterior resection surgery on Natividad. He
found that the malignancy in her sigmoid area had spread on her left ovary, necessitating the removal
of certain portions of it. Thus, Dr. Ampil obtained the consent of Natividad’s husband, Enrique Agana,
to permit Dr. Juan Fuentes, respondent in G.R. No. 126467, to perform hysterectomy on her.
Thereafter, Dr. Ampil took over, completed the operation and closed the incision. However, based on
the record of the hospital, the attending nurses indicated nota bene that 2 sponges were missing. The
same was reported to Dr. Ampil but were not found after “diligent seach”.
After couple of days, Natividad complained of excruciating pain in her anal region. She consulted both
Dr. Ampil and Dr. Fuentes about it. They told her that the pain was the natural consequence of the
surgery. Dr. Ampil then recommended that she consult an oncologist to examine the cancerous
nodes which were not removed during the operation. Natividad went to the United States for four
months but she was only declared free of cancer. In Natividad’s return to the Philippines, her
daughter found a piece of gauze protruding from her vagina. Upon being informed about it, Dr. Ampil
proceeded to her house where he managed to extract by hand a piece of gauze measuring 1.5
inches in width. He then assured her that the pains would soon vanish. But instead the pains
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intensified, prompting Natividad to seek treatment at the Polymedic General Hospital. While confined
there, Dr. Ramon Gutierrez detected the presence of another foreign object in her vagina — a foul-
smelling gauze measuring 1.5 inches in width which badly infected her vaginal vault . A recto-vaginal
fistula had formed in her reproductive organs which forced stool to excrete through the vagina.
Natividad underwent another surgical operation to remedy the damage. Civil and administrative
complaints, for damages and gross negligence respectively, were filed against Professional Services
Inc., owner of Medical City Hospital, Dr. Ampil and Dr. Fuentes.
ISSUE(S):
Are the following liable?
(1) Professional Services Inc., based on
(a) “employer-employee relationship”;
(b) “doctrine of apparent authority”;
(c) “corporate negligence”;
(2) Dr. Ampil,
(a) for medical negligence;
(b) under the “captain of the ship doctrine”;
(3) Dr.Fuentes, under the doctrine of res ipsa loquitor

HELD:(1) (a) YES.

[P]rivate hospitals, hire, fire and exercise real control over their attending and visiting ‘consultant’
staff. While ‘consultants’ are not, technically employees, x x x, the control exercised, the hiring, and
the right to terminate consultants all fulfill the important hallmarks of an employer-employee
relationship, with the exception of the payment of wages. In assessing whether such a relationship in
fact exists, the control test is determining. Accordingly, on the basis of the foregoing, we rule that for
the purpose of allocating responsibility in medical negligence cases, an employer-employee
relationship in effect exists between hospitals and their attending and visiting physicians.
(b) YES.
Apparent authority, or what is sometimes referred to as the “holding out” theory, or doctrine of
ostensible agency or agency by estoppel, has its origin from the law of agency. It imposes liability, not
as the result of the reality of a contractual relationship, but rather because of the actions of a principal
or an employer in somehow misleading the public into believing that the relationship or the authority
exists. xxx In this case, PSI publicly displays in the lobby of the Medical City Hospital the names and
specializations of the physicians associated or accredited by it, including those of Dr. Ampil and Dr.
Fuentes. We concur with the Court of Appeals’ conclusion that it “is now estopped from passing all
the blame to the physicians whose names it proudly paraded in the public directory leading the public
to believe that it vouched for their skill and competence.” Indeed, PSI’s act is tantamount to holding
out to the public that Medical City Hospital, through its accredited physicians, offers quality health
care services. By accrediting Dr. Ampil and Dr. Fuentes and publicly advertising their qualifications,
the hospital created the impression that they were its agents, authorized to perform medical or
surgical services for its patients. As expected, these patients, Natividad being one of them, accepted
the services on the reasonable belief that such were being rendered by the hospital or its employees,
agents, or servants.
(c) YES.
Hospital’s corporate negligence extends to permitting a physician known to be incompetent to
practice at the hospital. xxx [A] patient who enters a hospital does so with the reasonable expectation
that it will attempt to cure him. The hospital accordingly has the duty to make a reasonable effort to
monitor and oversee the treatment prescribed and administered by the physicians practicing in its
premises. In the present case, 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.
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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.
(2)
(a) YES.
This is a clear case of medical malpractice or more appropriately, medical negligence. To
successfully pursue this kind of case, a patient must only prove that a health care provider either
failed to do something which a reasonably prudent health care provider would have done, or that he
did something that a reasonably prudent provider would not have done; and that failure or action
caused injury to the patient. Simply put, the elements are duty, breach, injury and proximate
causation. 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. When he failed to do so, it was his duty to inform
Natividad about it. Dr. Ampil breached both duties. Such breach caused injury to Natividad,
necessitating her further examination by American doctors and another surgery. 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.
(b) YES.
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. 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.
(3) NO.
The requisites for the applicability of the doctrine of res ipsa loquitur are: (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.”
We find the element of “control and management of the thing which caused the injury” to be wanting.
Hence, the doctrine of res ipsa loquitur will not lie.
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.