THIRD DIVISION

[G.R. No. 250919. November 10, 2021.]

JUDE CARLO M. ALLAREY IN HIS OWN BEHALF, MINORS

HERO B. ALLAREY AND JUDE CARLO B. ALLAREY, JR., BY AND
THRU FATHER AND NATURAL GUARDIAN JUDE CARLO M.
ALLAREY, MINOR KAREN VALERIE B. SALAZAR AS
GUARDIAN AD LITEM, AND SPS. RUFO C. BACO, JR. AND
ROSALIE C. BACO, petitioners, vs. DR. MA. DITAS F. DELA
CRUZ AND MANILA EAST MEDICAL CENTER, respondents.

DECISION

CARANDANG, J : p

This resolves a Petition for Review on Certiorari 1 under Rule 45 of the

Rules of Court, assailing the Decision 2 dated May 30, 2019 and Resolution 3
dated November 13, 2019 of the Court of Appeals (CA) in CA-G.R. CV No.
110036.
Antecedents
Petitioners Jude Carlo M. Allarey (Jude), Hero B. Allarey (Hero), Jude
Carlo B. Allarey, Jr. (Jude, Jr.), Karen Valerie B. Salazar (Karen), Rufo C. Baco,
Jr. (Rufo) and Rosalie C. Baco (Rosalie) (collectively, petitioners) filed a
complaint for damages based on quasi-delict against Dr. Ma. Ditas F. Dela
Cruz (Dr. Dela Cruz) and Manila East Medical Center, Inc. (MEMCI). Jude is the
common-law partner of the late Marissa Baco (Marissa), a housewife who
died at 35 years old on August 29, 2006 after giving birth prematurely to
Julia Carla Allarey (Julia Carla) who died on August 30, 2006. Rufo and
Rosalie are the parents of Marissa while Jude, Jr. and Hero are Jude and
Marissa's common children. Karen is Marissa's daughter from a previous
relationship. 4
Dr. Dela Cruz performed cesarean section on Marissa when she gave
birth to Jude Jr. on August 18, 2005. On March 18, 2006, Marissa had a
check-up with Dr. Dela Cruz who confirmed that she was pregnant and her
estimated delivery was on November 4, 2006. Other pre-natal consultations
with Dr. Dela Cruz on Marissa were held on April 22, June 10, July 18, and
August 3, 2006. 5
In the afternoon of August 28, 2006, 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. She was given D-5LRS ampoules,
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 which were sourced by Jude and his friends outside MEMCI as the hospital's
pharmacy did not carry the drug. At about 8:00 p.m., Dr. Dela Cruz arrived at
the hospital, examined Marissa at the OR/DR, and described Marissa's
condition as "ok." She recommended that Marissa stay overnight for closer
monitoring. Once the bleeding stopped, Marissa would be transferred to
Room 511, as chosen by Jude. 6
On August 29, 2006, at about 9:30 a.m., Marissa sent Jude a text
message that she was transferred from the OR/DR to Room 511. At about
1:00 p.m., she sent him another text on her scheduled discharge from MEMCI
either in the late afternoon on the same day or on the next day. At past 2:00
p.m., 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. 7
While Jude was on his way to MEMCI, his sister called up and told him
that he had to sign a document as Marissa needed to undergo an operation.
He asked his sister to sign for him though it was his signature that was
required. At about 3:45 p.m., Jude arrived at MEMCI while his sister paid for
the type AB blood units needed for Marissa's operation. 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 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. 8 CAIHTE

In the morning of August 30, 2006, 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. 9
In her Answer, 10 Dr. Dela Cruz denied that she was negligent. She
narrated that at 6:00 p.m. on August 28, 2006, Marissa was confined at
MEMCI as she was experiencing labor pains and vaginal bleeding. The
admitting diagnosis was "Pregnancy Uterine, 30-31 weeks AOG, G4P3 in
preterm labor, previous Cesarian Section." She was directly brought to the
OR/DR with the following orders: Tocolysis (to prevent premature contraction
of patient's uterus); D5LRS, 1 liter with 4 ampules of Isoxilan; Diprospan,
12.5; and Intramuscularly every 12 hours for 2 doses. Laboratory
examinations consisting of Complete Blood Count and blood typing were
requested. Since she was having premature labor pains, she was advised to
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 have complete bed rest without bathroom privileges and that she must do all
necessities in bed until advised otherwise. She was also instructed not to
take anything by mouth temporarily. Her labor pains and vaginal bleeding
were strictly and constantly monitored. At 8:30 p.m., Dr. Dela Cruz did an
internal examination of Marissa's cervix and it was 1-2 centimeters dilated
with positive minimal bleeding. She stayed in the OR/DR for the next 14
hours without any untoward incident and there was no bleeding or
premature contraction during said period. 11 She was given the first dose of
Diprospan and the next dose was to be given at 8:30 a.m. the following day.
She was then allowed to have soft diet and was asked to have a room of her
choice once she showed stable vital signs. The next day, at around 1:00
p.m., Dr. Dela Cruz examined Marissa and noted that there was no
contraction and bleeding during her stay in the room. She informed Marissa
of the plan to discharge her late in the afternoon or the following day after
an ultrasound examination. It was at this time that Marissa suddenly
experienced profuse bleeding again. Dr. Dela Cruz immediately explained to
family members present in the room of her plan to perform an emergency
cesarian section and bilateral tubal ligation. She gave the necessary
instructions to the nurse on duty and arranged the surgical team and
anesthesiologist. 12 Marissa was wheeled into the operating room at around
2:20 p.m. Two units of fresh whole blood (FWB) type AB were requested
before the start of the operation. Marissa's hemoglobin level was 12.8 and
her hematocrit was 35.9. Marissa's vital signs and frequency of bleeding was
monitored while waiting for the blood and the pediatrician was on stand by
to receive the baby. At around 3:00 p.m., the patient was noted to have
profuse bleeding again. Her vital signs were still stable. Dr. Dela Cruz began
performing cesarian section at 3:10 p.m. and Julia Carla was delivered at
3:34 p.m. At this point, the anesthesiologist was still talking to the patient
and her vital signs were still stable. However, the bleeding was massive.
Hence, plasma expanders were immediately hooked. Dr. Dela Cruz noticed
that the placenta was deeply adherent to the uterine wall, hence her
decision to do emergency hysterectomy (removing of the entire uterus or
womb) at 3:40 p.m. The uterus was out at 4:20 p.m. and transfusion of FWB
type AB started. A referral to a urologist was made because of noted
adhesions in the patient's urinary bladder. At 4:45 p.m., a referral to an
internist-cardiologist was also made. At 5:20 p.m., a second unit of blood
was transfused. However, despite the emergency procedures, Marissa
succumbed to her death at about 5:45 p.m. 13 The final diagnosis of the
cause of death of Marissa, as supplied by Dr. Dela Cruz in Marissa's death
certificate, is "Cardio Respiratory Arrest secondary to Hypovolemic shock;
Placenta Accreta; T/C Amniotic Fluid Embolism." 14 Dr. Dela Cruz stressed
that "[a] negative outcome does not ipso facto imply negligence." 15
For the hospital's part, MEMCI contended in its Answer with
Counterclaim 16 that petitioners have no cause of action against it as there
was no employer-employee relationship between Dr. Dela Cruz and the
hospital. 17 MEMCI added that it exercised diligence of a good father of a
family in the selection, accreditation, and retention of its consultant
physicians. 18 The hospital also claimed that Marissa was a personal patient
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 of Dr. Dela Cruz in her lying-in clinic and was only brought to MEMCI for
emergency delivery due to preterm labor. The hospital emphasized that it
gives wide latitude of autonomy to its consultants or visiting doctors in the
diagnosis, care, and treatment of their patients such that when they are
admitted, it is the consultants who prescribe the appropriate treatment for
their patients. 19
Ruling of the Regional Trial Court
In a Decision 20 dated July 8, 2017, the RTC dismissed the complaint
against Dr. Dela Cruz and MEMCI. 21 The RTC found that petitioners were not
able to prove by preponderance of evidence that Dr. Dela Cruz failed to
observe the industry standard to treat the medical condition of Marissa.
Recognizing that this is a highly technical field, the RTC held that a
competent expert witness should have testified. Instead, petitioners only
presented the testimony of ordinary witnesses who had no medical
background. 22 While petitioners presented Dr. Olga M. Bausa (Dr. Bausa),
the medico-legal officer who performed an autopsy on Marissa, her
testimony was stricken off the record after she failed to appear during the
scheduled hearing dates for her cross-examination. Nevertheless, the RTC
noted that petitioners' own witness and evidence, Dr. Bausa's Medico-Legal
Report No. HO6-138 dated November 3, 2006, which was admitted into the
records, confirmed that:
x x x [T]he death is due to hypovolemic shock secondary to
postpartum bleeding due to placenta previa-associated accreta. The
manner of death is natural. 23
The RTC heavily relied on the medical records and expert witness
presented by Dr. Dela Cruz and MEMCI. The RTC found that the treatment
and management performed by Dr. Dela Cruz, the cesarian delivery of Julia
Carla, and the hysterectomy performed on Marissa to stop her bleeding were
the standard or conventional way of treating such conditions. She acted as
any other obstetrician would have acted under the same circumstances
doing all things which were under her control. The RTC recognized that
placenta accreta has a high mortality rate and found that the difficulty of
sourcing the rare blood type AB was proven. In conclusion, the RTC stated
that "[p]hysicians are not guarantors of successful results." 24
In an Order dated October 10, 2017, the RTC denied the Motion for
Reconsideration petitioners filed for lack of merit.
Ruling of the Court of Appeals
In a Decision 25 dated May 30, 2019, the CA denied the appeal of the
petitioners. 26 The CA held that the medical explanations petitioners offered,
through clippings from books and the internet, were never explained by any
expert witness. These informal sources were taken from foreign jurisdiction
and were dated after 2010, approximately four years after Marissa's surgery
in 2006. The CA agreed with the argument of Dr. Dela Cruz that what may be
the standard today may no longer be the standard tomorrow as the medical
field is constantly changing. 27 DETACa

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 The CA also found that Dr. German Tan Cardozo (Dr. Cardozo), the
expert witness Dr. Dela Cruz presented, was able to thoroughly explain that
Dr. Dela Cruz's diagnosis, treatment, and management of Marissa's case
were in accordance with sound obstetrical practice and standards. 28 The CA
was convinced that Marissa's condition, placenta accreta, was not something
Dr. Dela Cruz could have controlled. It was explained that while an
ultrasound could have been used to detect the condition, it may only provide
some suspicion that the patient has placenta accreta. Furthermore,
ultrasound may only delay management, aggravate the bleeding, and
stimulate the uterus into further contraction. 29 The only other way placenta
accreta could have been easily diagnosed is through surgery. 30 Since
Marissa's initial ultrasound did not show any abnormality in the placenta, Dr.
Cardozo testified that he himself would have no longer conducted another
ultrasound. 31
With regard to the contention of petitioners that MEMCI and Dr. Dela
Cruz failed to secure the required blood units prior to Marissa's operation, the
CA was satisfied with the explanation given by Dr. Cardozo that blood
transfusion only replaces the blood lost. Dr. Cardozo opined that if the source
of the bleeding is not removed, even if the doctors have sufficient supply of
blood, the bleeding will not stop. 32
The CA ruled that petitioners failed to prove the causal connection
between the injuries sustained and the purported negligence of Dr. Dela
Cruz and MEMCI. Causation must be proven within a reasonable medical
probability based upon competent expert testimony. However, petitioners
only presented non-medical witnesses, namely: Jude, Leila Esguerra (Leila),
Nina Allarey Ramos (Nina), and Princess Allarey (Princess). For the CA, these
witnesses have no competent knowledge on the standard of practice of
medical and obstetrical care required for Marissa's condition. The testimony
of the expert witness presented by petitioners, Dr. Bausa, was stricken off
the record for failing to attend scheduled hearings for her cross-examination.
Moreover, the CA gave credence to the medico-legal report Dr. Bausa
prepared wherein she categorically stated that "the manner of death is
natural" and did not indicate any act of negligence on the part of Dr. Dela
Cruz. 33
The CA also declared that the doctrine of res ipsa loquitur is not
applicable to the present case because Dr. Dela Cruz was not, in any way,
negligent in managing Marissa's case and that placenta accreta is beyond
the control of anyone. 34
In a Resolution 35 dated November 13, 2019, the CA denied the Motion
for Reconsideration of petitioners. 36
In the present petition, 37 it is argued that the failure of Dr. Dela Cruz
to diagnose placenta accreta at the earliest possible time caused Marissa to
have vaginal bleeding, rendering the hysterectomy procedure too late. 38
Petitioners suggested that Magnetic Resonance Imaging (MRI) and
ultrasound are accepted modes of detecting and diagnosing placenta
accreta 39 which Dr. Dela Cruz did not perform on Marissa during the critical
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 stage of her condition. 40 For petitioners, the lower courts should have
applied the doctrine of res ipsa loquitur. 41
Petitioners also maintained that Dr. Dela Cruz was negligent in not
adequately preparing the blood requirement for a hysterectomy procedure
despite the following factors: (1) Marissa was admitted on possible pre-term
labor; (2) Dr. Dela Cruz is aware that this is Marissa's 4th birth and her last
delivery was a cesarean delivery, hence the possibility of another surgery;
(3) Marissa was already bleeding when brought to MEMCI; and (4) Dr. Dela
Cruz was aware that Marissa's blood type AB is not readily available. 42
In her Comment, 43 Dr. Dela Cruz stressed that petitioners presented
only ordinary witnesses who can never lay down the standard of practice of
medical and obstetrical care needed under the prevailing circumstances. 44
She denied misdiagnosing the patient's pregnancy and insisted that she
skillfully and diligently performed what is expected of a prudent obstetrician
under the circumstances at that time. 45 She also maintained that the
doctrine of res ipsa loquitur is not applicable to the case. 46 She also argued
that there is no basis to award damages in favor of petitioners since they did
not present any evidence to support their allegation of negligence and the
standard of medical and obstetrical care needed at that time. 47
In a Letter 48 dated December 16, 2020, MEMCI manifested that it is
adopting in toto the Comment Dr. Dela Cruz filed. 49
Issues
The issues to be resolved in this case are:
1. Whether the doctrine of res ipsa loquitur is applicable to the
present case; and
2. Whether Dr. Dela Cruz and MEMCI were negligent in the
management and treatment of Marissa's medical condition that
caused her and Julia Carla's death, entitling petitioners to
damages.
Ruling of the Court
Despite the questions of fact raised in
the petition for review on certiorari,
the Court may give due course to
these petitions.
As a rule, issues dealing with the sufficiency of evidence and the
relative weight accorded to it by the lower court cannot be raised in a
petition for review on certiorari under Rule 45 which is confined to questions
of law. The Court does not review factual questions raised under Rule 45 as
it is not its function to analyze nor weigh all over again evidence already
considered in the proceedings below. Nevertheless, this rule is not absolute.
I n Microsoft Corp. v. Farajallah , 50 the Court declared that a review of the
factual findings of the lower court is proper in the following instances:
xxx xxx xxx
(3) when the inference made by the Court of Appeals from its
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 findings of fact is manifestly mistaken, absurd, or impossible;
xxx xxx xxx
(6) when the judgment of the Court of Appeals is premised on a
misapprehension of facts;
(7) when the Court of Appeals failed to notice certain relevant
facts which, if properly considered, would justify a different
conclusion[.] 51
xxx xxx xxx
In this case, a careful re-examination of the evidence on record is
necessary to determine whether the lower courts failed to notice and
properly appreciate certain relevant facts which, if properly considered,
would justify a different conclusion. There is a need to review the records to
confirm whether Dr. Dela Cruz and MEMCI have provided Marissa adequate
medical and obstetric care at the time she was admitted in MEMCI. aDSIHc

The doctrine of res ipsa loquitur

cannot be applied to the present case.
It is argued that the doctrine of res ipsa loquitur should be applied
instead of requiring petitioners to present an expert witness to prove Dr.
Dela Cruz and MEMCI's negligence. The doctrine of res ipsa loquitur is
derived from:
x x x [A] Latin phrase which literally means "the thing or the
transaction speaks for itself." The phrase "res ipsa loquitur" is a
maxim for the rule that the fact of the occurrence of an injury, taken
with the surrounding circumstances, may permit an inference or raise
a presumption of negligence, or make out a plaintiff's prima facie
case, and present a question of fact for defendant to meet with an
explanation. Where 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.
The doctrine of res ipsa loquitur is simply a recognition of the
postulate that, as a matter of common knowledge and experience,
the very nature of certain types of occurrences may justify an
inference of negligence on the part of the person who controls the
instrumentality causing the injury in the absence of some explanation
by the defendant who is charged with negligence. It is grounded in
the superior logic of ordinary human experience and on the basis of
such experience or common knowledge, negligence may be deduced
from the mere occurrence of the accident itself. Hence, res ipsa
loquitur is applied in conjunction with the doctrine of common
knowledge.
However, much has been said the res ipsa loquitur is not a
ruled of substantive law and, as such, does not create or constitute an
independent or separate ground of liability. Instead, it is considered
as merely evidentiary or in the nature of a procedural rule. It is
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 regarded as a mode of proof, of a mere procedural
convenience since it furnishes a substitute for, and relieves a
plaintiff of, the burden of producing specific proof of
negligence. In other words, mere invocation and application
of the doctrine does not dispense with the requirement of
proof of negligence. It is simply a step in the process of such
proof, permitting the plaintiff to present along with the proof
of the accident, enough of the attending circumstances to
invoke the doctrine, creating an inference or presumption of
negligence, and to thereby place on the defendant the burden
of going forward with the proof. Still, before resort to the doctrine
may be allowed, the following requisites must be satisfactorily shown:
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.
In the above requisites, the fundamental
element is the "control of the instrumentality"
which caused the damage. Such element of control
must be shown to be within the dominion of the
defendant. In order to have the benefit of the rule, a
plaintiff, in addition to proving injury or damage, must
show a situation where it is applicable, and must
establish that the essential elements of the doctrine were
present in a particular incident. 52 (Emphases supplied;
citations omitted)
A review of medical negligence cases brought to this Court reveals that
the doctrine of res ipsa loquitur is applied only to exceptional circumstances
where the failure to observe due care which caused injury to the patient is
readily apparent to a layman and is within the exclusive control of the erring
physician.
I n Cantre v. Spouses Go, 53 the Court applied the doctrine of res ipsa
loquitur to justify declaring the physician liable. The Court explained that the
gaping wound on the patient's arm is not an ordinary occurrence in the act
of delivering a baby and that such "injury could not have happened unless
negligence had set in somewhere." 54
I n Borromeo v. Family Care Hospital, Inc. , 55 the Court explained that
the application of the doctrine "require[s] expert opinion to establish the
culpability of the defendant doctor." 56 It also does not apply to cases where
the actual cause of the injury had been identified or established. 57
The declared cause of death of Marissa is "Cardio Respiratory Arrest
secondary to Hypovolemic shock; Placenta Accreta; T/C Amniotic Fluid
Embolism." 58 Placenta accreta refers to:
x x x [I]s a pregnancy condition in which the placenta attaches too
deeply into the wall of the uterus. The risk for developing accreta
increases with each C-section or uterine surgery. Other risk factors
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 include placenta previa, advanced maternal age, multiparity, and
curettage. Placenta accreta puts the mother at risk of severe blood
loss and other complications. The rates of maternal death,
transfusion, prolonged hospital stay and hysterectomy are all
increased for women with accreta. Placenta accreta spectrum (PAS) is
made up of three different levels of invasion: placenta accreta,
placenta increta, and placenta percreta. 59
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. This is clear from the testimony of Dr. Cardozo, the
relevant portion of which is reproduced below:
Q Now, what would cause placenta accreta or placenta increta?
A Multi-arity or maraming anak can cause it. But the more common
cause/s would be any type of instrumentation or scarring of the
uterus like a previous cesarian section, or previous myometric or
anything that was surgically done in the uterus can be exposed
to this condition.
Q So, is this condition of placenta increta or placenta accreta within
the control of a doctor?
A This condition arose from the pregnancy itself. It wasn't
brought about by an external force or something. 60
(Emphasis supplied)
Accordingly, the doctrine of res ipsa loquitur cannot be applied and
expert testimony must be resorted to in order to accurately determine the
standard of care necessary for Marissa's condition.
Dr. Dela Cruz and MEMCI were
negligent in the management and
treatment of Marissa's medical
condition that resulted to her and
Julia Carla's death.
Medical procedures are expectedly fraught with risks and uncertainties.
These may be compounded by negligence or malpractice. In medical
negligence cases, there are four elements that must be established: (1)
duty; (2) breach; (3) injury; and (4) proximate causation. 61 In litigations
involving medical negligence, the plaintiffs have the burden of establishing
these elements through the testimonies of expert witnesses. However, this
rule should not be strictly interpreted to mean that the failure to present any
expert witness on the part of the plaintiffs shall bar them from recovering
damages. An exception that should be recognized such as when the
testimony of the expert witness presented by the purported erring defendant
physician establishes the standard of care necessary under the given
circumstances and supports the claim of the plaintiffs, albeit indirectly. ETHIDa

Admittedly, petitioners, who are the plaintiffs in the complaint for

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 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.
This is particularly true when a careful analysis of the testimony of the
expert witness presented for the purported erring physician and hospital
reveals that it indirectly corroborates the claim of the heirs of Marissa.
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, as explained by Dr. Cardozo in the
following exchange:
Q May I go back to the Chief Complaint: Labor pain with vaginal
bleeding, Gestational Period: 30-31 weeks. Is it normal to have
pre-term labor within the gestational period of 30-31 weeks?
A Is it normal?
Q Yes, is it normal doctor?
A It is not normal but it commonly occurs.
Q But the point is, it is not normal?
A Yes, it is not normal.
Q What about bleeding sir, pre-term bleeding, is it normal to occur
with the gestational period of 30-31 weeks?
A It can occur, bleeding from pre-term labor.
Q But it is a departure from what is normal. Meaning it can but it's
not normal?
A It's a common manifestation, common symptom, common
complication of pre-term labor. 62 (Emphases supplied)
From the foregoing, it is clear that the condition of Marissa at the time
she was admitted to the hospital, though not normal, is a common
complication of preterm labor which a physician exercising the degree of
care, skill, and diligence in the same field of practice should have considered
and anticipated. 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.
Petitioners primarily anchor their claim that Dr. Dela Cruz and MEMCI
were negligent in the treating Marissa in the fact that Marissa was not
subjected to ultrasound or MRI to properly diagnose her condition. Dr.
Cardozo himself acknowledged that ultrasound and MRI are recognized
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 preoperative techniques for diagnosing placenta accreta:
Q Have you come across the journal saying that sonography or MRI
may help determine?
A Yes sir, it may help determine.
Q How about ultrasound, can it help determine?
A It may help sir. 63 (Emphases supplied)
However, instead of instructing that an ultrasound or MRI be
performed, Dr. Dela Cruz only ordered tocolysis which refers to:
x x x [A]n obstetrical procedure carried out with the use of
medications with the purpose of delaying the delivery of a
fetus in women presenting preterm contractions. These
medications are administered with the hope of decreasing
fetal morbidity and mortality. Tocolysis is intended to prolong
gestation for two to seven days and works by creating a
quiescent environment in the uterus. This is important to allow
transportation to a higher care facility, to administer a fetal lung
maturity scheme with antenatal corticosteroids, and the additional
time is also used to determine the group B streptococcus (GBS)
status of the pregnant woman, and provide prophylaxis if she is either
positive or the GBS culture status is unknown.
Tocolysis is not intended to increase gestation of the
fetus to term but is focused on providing a window of time to
support treatments that have been shown to improve
outcomes for delivery. 64 (Emphases supplied)
Though tocolysis or the postponement of preterm labor was the
immediate medical treatment performed on Marissa to address the
premature contractions, it is clear from the records that there were no
efforts to determine the cause of the bleeding, as revealed in the following
exchange:
Q You said that tocolysis is meant to stop the contraction?
A Yes sir.
Q But it is not directed to stop the bleeding?
A It is a way to stop the bleeding, because when the uterus
contracts, it pulls away from the implantation site that cause the
bleeding.
Q Do you know the other causes of bleeding? For example
placental abruption?
A It can cause.
Q Can it be caused by placental previa sir?
A Yes sir.
Q Can it be caused by cramps?
A It's a vague term sir.
Q I'm trying to be a doctor, sir, that is why please you have to
guide me. May I read from Emily Blanky, MD, "when spotting or
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 bleeding is accompanied by contractions or cramping, it can be
an indication of cervical dilation." So it can be a cause of
bleeding?
A Yes sir.
Q So we have made clear of it. How about a minor trauma on the
surface of vagina, can it also cause bleeding?
A Yes sir.
Q Now, tell this Honorable Court were there efforts on the part of
defendant Dela Cruz to determine the cause of the bleed at the
time of the admission?
xxx xxx xxx
Q At the time of the admission based on the Medical Abstract?
A I don't know what action she did, what I saw was there
was ultrasound. cSEDTC

Q May I get the answer again?

A I don't know what actions the doctor did during that time of her
encounter with the patient.
Q But you will agree with me sir that the Abstract should capture
whatever things or acts the defendant doctor did at the time of
admission?
A If it was recorded completely.
Q So you will agree with me sir with this Exhibit "4", the Clinical
Abstract, there was nothing that talks about the efforts to
determine the cause of bleeding, right sir?
A Well if you want my opinion, there was an ultrasound
report. 65 (Emphasis supplied)
It must be clarified that there was no ultrasound nor MRI conducted on
Marissa during her confinement at MEMCI. In his testimony quoted above,
Dr. Cardozo erroneously referred to the ultrasound conducted on Marissa on
July 18, 2006, more than a month before she experienced premature
contractions and bleeding. This error was made apparent in the following
exchange:
Q Ultrasound?
A But it did not mention about placenta previa.
Q You are referring sir to the latest ultrasound dated July 18, 2006,
and I think you identified this evidence, too?
A I don't remember the date sir.
Q May I confront you with it? In fact in your direct examination, you
mentioned that among the documents you examined or based
upon your opinion was the ultrasound, right sir?
A Come again?
Q On page 15 of the transcript, you mentioned that you based your
opinion on the ultrasound?

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 ATTY. REBOSA:
"Eto sir, previously marked as Exhibit "J" your Honor."
ATTY. CAMARA:
Thank you.
Q Here sir. May I confront you with the ultrasound performed on the
date in question, "Single Right (sic) Intrauterine Pregnancy of
about 26 weeks and 2 days Age of Gestation, Anterior Placenta
Grade I-II," is that the one?
A Yes sir.
Q And the date of death of course of Marissa Baco Allarey,
occurred on August 29, 2006?
A Yes sir.
Q Going backward, related to the latest ultrasound on July
18, 2006, there was no more ultrasound taken?
A I have no copy of the . . . that's the one that was
provided.
Q At least you did not refer to any other ultrasound except
the latest?
A Yes sir.
Q July 18, 2006, Exhibit "J"?
A Yes sir. 66 (Emphases supplied)
It is certain from the foregoing that Dr. Cardozo formed his opinion on
an ultrasound report prepared on July 18, 2006 or more than a month before
Marissa was confined. At that time, the signs and symptoms suggesting any
irregularity in the placenta of the patient may not have been existing or
apparent yet. Despite acknowledging that ultrasound and MRI are recognized
methods for diagnosing placenta accreta, Dr. Cardozo failed to address why
Dr. Dela Cruz did not timely instruct an ultrasound or MRI when Marissa was
confined at the hospital.
Dr. Dela Cruz underestimated the extent of Marissa's condition which
led to the deterioration of her condition. The factors that made Marissa's
pregnancy high risk should have put her on guard. The necessity of timely
diagnosis through ultrasound was made apparent in the testimony of Dr.
Cardozo quoted below:
Q Now, given the fact that this lady is of G4P3, four pregnancies,
three deliveries and one cesarian section, would you not say that
the high index of suspicion should have prompted the doctor to
look into the matter why there was a threatened delivery when
she was admitted to the hospital on August 28, 2006 at 6:00 in
the evening?
A Maybe she would have thought of that, the ultrasound, if she
were to base on the ultrasound there was no indication.
Q And that was the time that we agreed that when you say
"ultrasound," you were referring actually to?
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 A The latest ultrasound.
xxx xxx xxx
Q And that was supposed to be dated July 18, 2006, right?
A Yes, sir.
Q And this is supposed to be so many days before her death on
August 29, 2006?
A Yes, sir. 67 (Emphasis and italics in the original; underscoring
supplied)
Again, the ultrasound that Dr. Cardozo conducted is more than a
month before Marissa complained of bleeding and labor contractions.
Between the date of Marissa's last ultrasound, July 18, 2006, and the date
she was admitted to the hospital, August 28, 2006, there could have been
significant changes in her health that would have warranted a more recent,
accurate, and reliable ultrasound.
To the Court's mind, the fact that Dr. Dela Cruz failed to timely and
properly diagnose the condition of Marissa which could have averted her
death and Julia Carla's death was revealed in the testimony of Dr. Cardozo
quoted below:
Q Now, may I go to the hypothesis that the good doctor did not do
any of these ultrasounds, transvaginal or transabdominal, what is
your conclusion?
A My conclusion? Well based on the records, she was just
considering just plain pre-term labor. Based on the
previous ultrasound it did not show any previa or accrete,
and that's the very first thing that an Obstetrician would
think of, pre-term labor and she would give tocolysis and
that's the management we observed in the process.
Q She did not entertain any abnormal implantation, is that what
you mean?
A Yes, because based on the previous ultrasound it was not
recorded. 68
Instead of addressing the bleeding, she downplayed its seriousness
despite knowledge of her medical background and the presence of factors
that made her pregnancy high-risk. This was her fourth pregnancy, had
three previous deliveries, and her last childbirth delivery was through
cesarean section, giving her a higher probability of having placenta accreta
o r previa. She relied on an ultrasound report prepared more than a month
before the patient complained of premature contractions and bleeding.
Moreover, the conclusion of Dr. Cardozo that he would have acted the
same way as Dr. Dela Cruz did under the same circumstances should not be
construed to mean that she was not negligent in treating Marissa during the
period leading up to the sudden deterioration of her condition at 1:00 p.m.
on August 29, 2006. The context of his conclusion should be construed to
mean that what he was referring to was the emergency cesarean operation
and hysterectomy conducted on Marissa which are, concededly, the
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 standard of care necessary when bleeding could no longer be controlled or
her condition at 1:00 p.m. on August 29, 2006. With regard to the standard
of care or treatment necessary prior to the period when bleeding could no
longer be controlled, the necessity of timely diagnosis through ultrasound
could be drawn from the respondent physician's own expert witness in the
following exchange:
Q Could not these words anterior placenta, using the high index of
suspicion , prompted the good doctor to conduct another
ultrasound to pacify herself because right there the patient was
bleeding?
A Maybe. Maybe she was just waiting for the patient to be in a
stable condition before requesting for another ultrasound.
xxx xxx xxx
Q Because there was no ultrasound since it was not done. Look at
this, Doctor, you said you would have wanted the patient to be
stable but there was so much time to do it from 9:00 am to 1:10
pm, isn't it, Doctor?
SDAaTC

xxx xxx xxx

A There was no ultrasound performed. 69 (Emphasis supplied)
Noticeably, Dr. Dela Cruz admitted that there were minimal bleeding
and contraction between 8:30 pm of August 28, 2006 and 1:00 pm the next
day. During this period, Dr. Dela Cruz could have ordered Marissa's
ultrasound or MRI yet she did not give such instruction. Timely and proper
diagnosis of Marissa's condition could have prevented or mitigated the
severe complications she suffered that led to her and her baby's death. Had
placenta accreta been diagnosed early, emergency cesarean section and
hysterectomy procedure could have immediately been performed to address
her bleeding instead of waiting for several hours. By the time Dr. Dela Cruz
performed these emergency procedures, it was already too late because
bleeding could no longer be controlled. Hence, when the testimonies of Dr.
Cardozo and Dr. Dela Cruz are taken together with the evidence of
petitioners, it could be seen that adequate measures were not taken to
provide Marissa the appropriate care necessary for her high-risk pregnancy.
Furthermore, given the fact that there was at least a period of 16 hours
from the time Dr. Dela Cruz physically examined Marissa and the time she
experienced profuse bleeding again the next day, Dr. Dela Cruz and the
hospital should have already started sourcing blood supply that may be
needed by the patient in case of emergency, especially since her blood type
is rare. Knowing that the pregnancy of Marissa is high-risk and that she was
already bleeding when she was brought to the hospital, timely and adequate
preparation for potential emergency surgery was critical and could have
saved her and the baby.
MEMCI is vicariously liable for the
negligence of Dr. Dela Cruz.
MEMCI is vicariously liable for Dr. Dela Cruz's negligence based on
Article 2180 of the Civil Code, which states:
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 Article 2180. The obligation imposed by Article 2176 is
demandable not only for one's own acts or omissions, but also for
those of persons for whom one is responsible.
xxx xxx xxx
Employers shall be liable for the damages caused by their employees
and household helpers acting within the scope of their assigned tasks,
even though the former are not engaged in any business or industry.
xxx xxx xxx
The responsibility treated of in this article shall cease when the
persons herein mentioned prove that they observed all the diligence
of a good father of a family to prevent damage.
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.
The heirs of Marissa are entitled to
damages.
Under the Civil Code, when an injury has been sustained, actual
damages may be awarded under the following condition:
Article 2199. Except as provided by law or by stipulation, one is
entitled to an adequate compensation only for such pecuniary loss
suffered by him as he has duly proved. Such compensation is
referred to as actual or compensatory damages. (Emphasis supplied)
Thus, only the expenses proven by credible evidence may be awarded.
In this case, the medical, funeral, and burial expenses amounting to
P180,967.00 were duly supported with official receipts presented during
trial.
Civil or death indemnity is mandatory and granted to the heirs of the
victim without need of proof other than the commission of the crime. Initially
fixed by the Civil Code at P3,000.00, the amount of the indemnity is
currently fixed at P50,000.00. 71 Thus, the heirs of Marissa are entitled to
P50,000.00 for her death. An additional P50,000.00 is also awarded for the
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 death of Julia Carla.
With regard to the award of moral damages, Article 2206 of the Civil
Code expressly grants moral damages in addition to the award of civil
indemnity. The Court finds an award of P100,000.00 as moral damages
sufficient to answer for the mental anguish suffered by the heirs of Marissa
because of the untimely passing of Marissa and Julia Carla.
In addition, the Court awards exemplary damages upon finding that Dr.
Dela Cruz and MEMCI were grossly negligent in failing to provide Marissa the
standard of care necessary to treat her condition. To ensure that similar
conduct will not be repeated, Dr. Dela Cruz and MEMCI are directed to
solidarily pay P50,000.00 as exemplary damage to the heirs of Marissa.
With respect to the award of litigation expenses and attorney's fees,
the Civil Code allows attorney's fees to be awarded if, as in this case,
exemplary damages are imposed. Considering the protracted litigation of
this dispute, an award of P50,000.00 as attorney fees is awarded to the heirs
of Marissa.
Legal interest should also be awarded in accordance with the Court's
ruling in Nacar v. Gallery Frames . 72 In said case, the Court provided
guidelines for the imposition of interest rates on the basis of Bangko Sentral
ng Pilipinas Monetary Board (BSP-MB) Circular No. 799, which took effect on
July 1, 2013, thus:
II. With regard particularly to an award of interest in the concept
of actual and compensatory damages, the rate of interest, as well as
the accrual thereof, is imposed, as follows:
xxx xxx xxx
2. When an obligation, not constituting a loan or
forbearance of money, is breached, an interest on the
amount of damages awarded may be imposed at the
discretion of the court at the rate of 6% per annum. No
interest, however, shall be adjudged on unliquidated
claims or damages except when or until the demand can
be established with reasonable certainty. Accordingly,
where the demand is established with reasonable
certainty, the interest shall begin to run from the time the
claim is made judicially or extrajudicially (Art. 1169, Civil
Code) but when such certainty cannot be so reasonably
established at the time the demand is made, the interest
shall begin to run only from the date the judgment of the
court is made (at which time the quantification of
damages may be deemed to have been reasonably
ascertained). The actual base for the computation of legal
interest shall, in any case, be on the amount finally
adjudged.
3. When the judgment of the court awarding a sum of
money becomes final and executory, the rate of legal
interest, whether the case falls under paragraph 1 or
paragraph 2, above, shall be 6 % per annum from such
finality until its satisfaction, this interim period being
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 deemed to be by then an equivalent to a forbearance of
credit.
xxx xxx xxx
And in addition to the above, judgments that have become final
and executory prior to July 1, 2013, shall not be disturbed and shall
continue to be implemented applying the rate of interest fixed
therein. 73 (Emphasis and italics in the original; Citations omitted)EcTCAD

Accordingly, when an obligation, not constituting a loan or forbearance

of money, is breached, an interest on the amount of damages awarded may
be imposed at the discretion of the court at the rate of six percent (6%) per
annum. 74 The reckoning point for the interest, when imposed on
unliquidated claims or damages such as actual, moral, and exemplary
damages, is set on the date of the judgment of the court granting the award
since it is only at such time when the amount claimed becomes "liquidated,"
that is, determined with reasonable certainty. Since damages are being
awarded only at this stage of the proceedings, the award actual, moral, and
exemplary damages shall earn six percent (6%) interest per annum
computed from the date of this Decision, until full satisfaction of the award.
Thereafter, the total monetary award, including interests, shall begin to
earn legal interest at six percent (6%) per annum from the finality of this
Decision until full payment because during the interim period, the total
monetary award is considered equivalent to a forbearance of credit.
WHEREFORE, the Decision of the Court of Appeals dated May 30,
2019 and the Resolution dated November 13, 2019 in CA-G.R. CV No.
110036 are SET ASIDE. Respondents Dr. Ma. Ditas F. Dela Cruz and Manila
East Medical Center, Inc. are jointly and severally liable to pay the heirs of
Marissa Baco the following:
a. P180,967.00 as actual damages;
b. P200,000.00 as civil indemnity for the death of Marissa Baco and
Julia Carla Allarey;
c. P100,000.00 as moral damages;
d. P50,000.00 as exemplary damages;
f. n  Interest on the total monetary award in (a), (b), (c), and (d) at the
rate of six percent (6%) per annum reckoned from the date of
this Decision until full satisfaction of the award;
g. P50,000.00 as attorney's fees; and
h. Costs of suit.
The total amount of the foregoing shall, in turn, earn interest at the
rate of six percent (6%) per annum from finality of this Decision until full
payment thereof in compliance with the Court's ruling in Nacar v. Gallery
Frames.
SO ORDERED.
Leonen, Zalameda, Rosario and Dimaampao, * JJ., concur.
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 Footnotes

* Designated as additional Member per Special Order No. 2839 dated September
16, 2021.
1. Rollo , pp. 21-56.

2. Penned by Associate Justice Ronaldo Roberto B. Martin, with the concurrence of

Associate Justices Ramon M. Bato, Jr. and Ramon A. Cruz; id. at 59-79.
3. Id. at 80-81.

4. Id. at 60.
5. Id.

6. Id. at 60-61.

7. Id. at 61.
8. Id. at 61-62.

9. Id. at 62.

10. Records, pp. 51-61.

11. Rollo , pp. 63-64.

12. Id. at 63.

13. Records, pp. 55-56.

14. Id. at 25.

15. Id. at 58.

16. Id. at 106-114.

17. Id. at 109.

18. Id. at 110.

19. Id. at 111-112.

20. Penned by Presiding Judge Dennis Patrick Z. Perez; CA rollo, 23-47.

21. Id. at 47.

22. Id. at 28-29.

23. Id. at 29.

24. Id. at 47.

25. Supra note 2.

26. Rollo , p. 78.

27. Id. at 68-69.

28. Id. at 69-72.
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 29. Id. at 73-76.

30. Id. at 72.

31. Id. at 76.

32. Id. at 73.

33. Id. at 77.

34. Id. at 78.

35. Supra note 3.

36. Rollo , p. 81.

37. Id. at 21-56.

38. Id. at 37.

39. Id. at 38-39.

40. Id. at 46.

41. Id. at 51.

42. Id. at 43.

43. Id. at 144-166.

44. Id. at 145.

45. Id. at 145-147.

46. Id. at 149.

47. Id. at 163-165.

48. Id. at 182.

49. Id.
50. 742 Phil. 775 (2014).

51. Id. at 785.

52. Ramos v. Court of Appeals , 378 Phil. 1198, 1219-1221 (1999).

53. 550 Phil. 637 (2007).

54. Id. at 647.

55. 779 Phil. 1 (2016).

56. Id. at 22.

57. Id.

58. Records, p. 25.

59. Accessed at <https://www.preventaccreta.org/accreta>.

60. TSN dated February 21, 2014, p. 26.
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 61. Cayao-Lasam v. Spouses Ramolete , 595 Phil. 56, 73 (2008).
62. TSN dated March 14, 2014, pp. 18-19.

63. TSN dated March 14, 2014, p. 22.

64. Mayer C, Apodaca-Ramos I. Tocolysis. In: StatPearls [Internet]. Treasure Island

(FL): StatPearls Publishing; 2021.
<https://www.ncbi.nlm.nih.gov/books/NBK562212/> visited August 9, 2021.

65. TSN dated March 14, 2014, pp. 22-25.

66. Id. at 25-26.

67. TSN dated August 8, 2014, pp. 18-19.

68. TSN dated March 14, 2014, p. 33.

69. TSN dated August 8, 2014, pp. 21-22.

70. Nogales v. Capitol Medical Center, 540 Phil. 225, 246 (2006).

71. Torreon v. Aparra, Jr., 716 Phil. 267 (2013).

72. 716 Phil. 267 (2013).

73. Id. at 279.

74. Id.

n Note from the Publisher: Copied verbatim from the official document. Irregular
alphabetical sequence.

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