Dr. Rubi Li, Petitioner, vs. Spouses Reynaldo and Lina Soliman, as parents/heirs of deceased Angelica Soliman, Respondents.

G.R. No. 165279

June 7, 2011
Legal Issue: How is medical malpractice proven?
Legal Facts:
Respondents 11-year old daughter, Angelica Soliman, underwent a biopsy of the mass located in her lower extremity at the St. Lukes
Medical Center (SLMC) on July 7, 1993 and results showed that Angelica was suffering from osteosarcoma, osteoblastic type, (highly malignant)
cancer of the bone because of that a necessity of amputation was conducted by Dr, Tamayo on Angelicas right leg in order to remove the tumor
and to prevent the metastasis that chemotherapy was suggested by Dr. Tamayo, which he referred to petitioner Dr. Rubi Li, a medical oncologist.
The respondent was admitted to SLMC on August 18, 1993; however, she died eleven (11) days after the (intravenous) administration of
chemotherapy first cycle. Respondents brought their daughters body to the Philippine National Police (PNP) Crime Laboratory at Camp Crame for
post-mortem examination after the refusal of the hospital to release the death certificate without full payment of bills. The Medico-Legal Report
showed that the cause of death as "Hypovolemic shock secondary to multiple organ hemorrhages and Disseminated Intravascular Coagulation.
The respondents filed charges against the SLMC and physicians involve for negligence and failure to observe the essential precautions in to
prevent Angelicas untimely death. Petitioner denied the allegation for damages as she observed best known procedures, highest skill and
knowledge in the administration of chemotherapy drugs despite all efforts the patient died. The trial court was in favor of the petitioner and ordered
to pay their unpaid hospital bill in the amount of P139, 064.43, but the Court of Appeals reversed the decision supporting the respondents pray.
Holding:
In this case medical malpractice is proven because the four essential elements of such action are present based upon the doctrine of
informed consent.
Reasoning:
There are four essential elements a plaintiff must prove in a malpractice action based upon the doctrine of informed consent: "(1) the
physician had a duty to disclose material risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a direct and proximate result of
the failure to disclose, the patient consented to treatment she otherwise would not have consented to; and (4) plaintiff was injured by the proposed
treatment." Informed consent case requires the plaintiff to "point to significant undisclosed information relating to the treatment that would alter her
decision to undergo. The physician is not expected to give the patient a short medical education, the disclosure rule only requires of him a
reasonable general explanation in nontechnical terms.
Policy Formation:
In all sorts of medical procedures either invasive or not, medical institution must have a certificate of competency in rendering standards
of care to delicate medical procedures before initiating a general protocol that would establish a guideline principle in a form of proper disclosure of
such procedure and presenting a consent or waiver to their patients so that possible future medico-legal suits will be prevented.
Synthesis:
In Dr. Rubi Li, vs. Spouses Reynaldo and Lina Soliman, as parents/heirs of deceased Angelica Soliman, Respondents, G.R. No. 165279,
promulgated on June 7, 2011, the Court ruled that medical malpractice is proved base on lack/impaired informed consent, and reasonable expert
testimony subject a breach of duty causing gross injury to its patient.

Dr. Ninevetch Cruz v. CA and Lydia Umali

1997 / Francisco / Petition for review on certiorari of a CA decision
Standard of conduct > Experts > Medical professionals
FACTS
Medical malpractice suit type of claim which a victim has available to him/her to redress a wrong committed by a medical professional which
has caused bodily harm; most often brought as a civil action for damages under NCC 2176 or a criminal case under RPC 365, with which a civil
action for damages is impliedly instituted.
Lydia Umali was examined by Dr. Cruz who found a myoma [benign tumor] in her uterus, and scheduled her for a hysterectomy
operation [removal of uterus] on 23 Mar 1991. Rowena Umali de Ocampo accompanied her mother to the hospital a day before the operation, and
they spent the night there. Rowena noticed that the clinic was untidy, so she tried to persuade her mother not to proceed with the operation. The
following day, Rowena asked Dr. Cruz if the operation could be postponed, but Lydia told her daughter that Dr. Cruz said that the operation must go
on as scheduled.
While Lydias relatives were waiting, Dr. Ercillo (anesthesiologist) told them to buy tagamet ampules, and Rowenas sister went out to
buy some. An hour later, Dr. Ercillo asked them to buy blood for Lydia, so they did. A few hours later, the operation was finished, but later, Dr. Cruz
asked the family to buy additional blood, but there was no more type A blood available in the blood bank. A person arrived to donate
blood which was later transfused to Lydia. Rowena noticed that her mother was gasping for breathapparently, the oxygen supply had run out,
so the family went out to buy oxygen. Later in the evening, she went into shock and her blood pressure dropped. She was then transferred to
another hospital so she could be connected to a respirator and further examined. However, this transfer was without the consent of the
relatives, who only found out about it when an ambulance came to take Lydia to the other hospital.
In the new hospital, she was re-operated upon by Dr. Cruz and Dr. Ercillo because blood was oozing out from her incision. They
summoned Dr. Angeles, Ob-Gyne head of the new hospital, but when he arrived, Lydia was already in shock and possibly dead (BP: 0/0). Dr.
Angeles told Drs. Cruz and Ercillo that there was nothing he could do. Lydia died while Dr. Cruz was closing her abdominal wall. Immediate cause
of death is shock; disseminated intravascular coagulation (DIC) as antecedent cause.
Dr. Cruz and Dr. Ercillo were charged with reckless imprudence and negligence resulting in homicide of Lydia Umali. The Municipal
Trial Court in Cities (MTCC) found Dr. Ercillo not guilty for insufficiency of evidence against her, but held Dr. Cruz responsible for Umalis
death. RTC and CA affirmed MTCC.
Manifestation of negligence

untidiness of clinic

lack of provision of supplies

the fact that the transfer was needed meant that there was something wrong in the way Dr. Cruz conducted operation

no showing that pre-surgery procedure (clearance, blood typing/tests) was conducted

ISSUE AND HOLDING
WON the circumstances are sufficient to sustain a judgment of conviction against Dr. Cruz for reckless imprudence resulting in homicide. NO. DR.
CRUZ IS ACQUITTED, BUT SHE IS STILL CIVILLY LIABLE (50K civil liability; 100k moral damages, 50k exemplary damages).
RATIO
Elements of reckless imprudence
1. Offender does / fails to do an act
2. Doing / failure to do act is voluntary
3. Without malice
4. Material damage results from reckless imprudence
5. There is inexcusable lack of precaution, taking into consideration offenders employment, degree of intelligence, physical condition, other
circumstances re: persons, time, place
Standard of care
Standard of care observed by other members of the profession in good standing under similar circumstances, bearing in mind the advanced state
of the profession at the time of treatment or the present state of medical science
When the physicians qualifications are admitted, there is an inevitable presumption that in proper cases, he takes the necessary precaution
and employs the best of his knowledge and skill in attending to his clients, unless the contrary is sufficiently established by expert testimony.
Expert testimony
Expert testimony is essential to establish standard of care of the profession, as well as that the physicians conduct in the treatment and care falls
below such standard. It is also usually necessary to support the conclusion as to causation. There is an absence of any expert testimony re:
standard of care in the case records. NBI doctors presented by the prosecution only testified as to the possible cause of death.
While it may be true that the circumstances pointed out by the lower courts constitute reckless imprudence, this conclusion is still
best arrived not through the educated surmises nor conjectures of laymen, including judges, but by the unquestionable knowledge of
expert witnesses. The deference of courts to the expert opinion of qualified physicians stems from the realization that the latter
possess unusual technical skills which laymen are incapable of intelligently evaluating.
Burden of establishing medical negligence on plaintiff
Plaintiff has the burden to establish this, and for a reasonable conclusion of negligence, there must be proof of breach of duty on the part of the
surgeon, as well as a causal connection of such breach and the resulting death of patient. Negligence cannot create a right of action unless it is the

proximate cause of the injury complained of (Chan Lugay v. St. Lukes Hospital, Inc.). In this case, no cogent proof exists that the circumstances
caused Lydias death, so the 4th element of reckless imprudence is missing.
The testimonies of the doctors presented by the prosecution establish hemorrhage / hemorrhagic shock as the cause of death, which may be
caused by several different factors. Autopsy did not reveal any untied cut blood vessel, nor was there a tie of a cut blood vessel that became
loose. The findings of the doctors do not preclude the probability that a clotting defect (DIC) caused the hemorrhage and consequently,
Lydias death.
The Court has no recourse but to rely on the expert testimonies that substantiate Dr. Cruz allegation that the cause of Lydias death was DIC, which
cannot be attributed to Dr. Cruz fault or negligence. This probability was unrebutted during trial.
1

Civil liability of person who is criminally liable includes restitution of thing even though it is with a third person who acquired it legally
Although possession of movable property acquired in good faith is equivalent to a title, one who has lost any movable or has been unlawfully
deprived thereof may recover it from the person who possesses it.
2

Professional Services Inc. v. Agana

Professional Services Inc. (PSI) v. Natividad and Enrique Agana
Natividad and Enrique Agana v. Juan Fuentes
Miguel Ampil v. Natividad and Enrique Agana
2007 / Sandoval-Gutierrez / Petition for review on certiorari of CA decisions
Standard of conduct > Experts > Medical professionals
FACTS
Natividad Agana was rushed to Medical City because of difficulty of bowel movement and bloody anal discharge. Dr. Ampil diagnosed her to be
suffering from cancer of the sigmoid. Dr. Ampil performed an anterior resection surgery on her, and finding that the malignancy spread on her
left ovary, he obtained the consent of her husband, Enrique, to permit Dr. Fuentes to perform hysterectomy on her. After the hysterectomy, Dr.
Fuentes showed his work to Dr. Ampil, who examined it and found it in order, so he allowed Dr. Fuentes to leave the operating room. Dr. Ampil was
about to complete the procedure when the attending nurses made some remarks on the Record of Operation: sponge count lacking 2;
announced to surgeon search done but to no avail continue for closure (two pieces of gauze were missing). A diligent search was
conducted but they could not be found. Dr. Ampil then directed that the incision be closed.
A couple of days after, she complained of pain in her anal region, but the doctors told her that it was just a natural consequence of the
surgery. Dr. Ampil recommended that she consult an oncologist to examine the cancerous nodes which were not removed during the operation.
After months of consultations and examinations in the US, she was told that she was free of cancer. Weeks after coming back, her daughter found
a piece of gauze (1.5 in) protruding from her vagina, so Dr. Ampil manually extracted this, assuring Natividad that the pains will go away. However,
the pain worsened, so she sought treatment at a hospital, where another 1.5 in piece of gauze was found in her vagina. She underwent another
surgery.
Sps. Agana filed a complaint for damages against PSI (owner of Medical City), Dr. Ampil, and Dr. Fuentes, alleging that the latter are liable
for negligence for leaving 2 pieces of gauze in Natividads body, and malpractice for concealing their acts of negligence. Enrique Agana also filed
an administrative complaint for gross negligence and malpractice against the two doctors with the PRC (although only the case against Dr.
Fuentes was heard since Dr. Ampil was abroad). Pending the outcome of the cases, Natividad died (now substituted by her children). RTC found
PSI and the two doctors liable for negligence and malpractice. PRC dismissed the case against Dr. Fuentes. CA dismissed only the case
against Fuentes.
ISSUE AND HOLDING
1.
WON CA erred in holding Dr. Ampil liable for negligence and malpractice. NO; DR. AMPIL IS GUILTY
2.
WON CA erred in absolving Dr. Fuentes of any liability. NO
3.
WON PSI may be held solidarily liable for Dr. Ampils negligence. YES
RATIO
DR. AMPIL IS LIABLE FOR NEGLIGENCE AND MALPRACTICE
His arguments are without basis [did not prove that the American doctors were the ones who put / left the gauzes; did not submit evidence to rebut
the correctness of the operation record (re: number of gauzes used); re: Dr. Fuentes alleged negligence, Dr. Ampil examined his work and found it
in order].
Leaving foreign substances in the wound after incision has been closed is at least prima facie negligence by the operating
surgeon. Even if it has been shown that a surgeon was required to leave a sponge in his patients abdomen because of the dangers attendant
upon delay, still, it is his legal duty to inform his patient within a reasonable time by advising her of what he had been compelled to do , so she can
seek relief from the effects of the foreign object left in her body as her condition might permit. Whats worse in this case is that he misled her by
saying that the pain was an ordinary consequence of her operation.

Medical negligence; standard of diligence

To successfully pursue this case of medical negligence, a patient must only prove that a health care provider either failed to do something [or did
something] which a reasonably prudent health care provider would have done [or wouldnt have done], and that the failure or action caused injury to
the patient.

Duty - to remove all foreign objects from the body before closure of the incision; if he fails to do so, it was his duty to inform the patient
about it

Breach failed to remove foreign objects; failed to inform patient

Injury - suffered pain that necessitated examination and another surgery

Proximate Causation - breach caused this injury; could be traced from his act of closing the incision despite information given by the
attendant nurses that 2 pieces of gauze were still missing; what established causal link: gauze pieces later extracted from patients vagina
DR. FUENTES NOT LIABLE
The res ipsa loquitur [thing speaks for itself] argument of the Aganas does not convince the court. Mere invocation and application of this doctrine
does not dispense with the requirement of proof of negligence.
Requisites for the applicability of res ipsa loquitur
1.
Occurrence of injury
2.
Thing which caused injury was under the control and management of the defendant [DR. FUENTES] LACKING SINCE CTRL+MGT
WAS WITH DR. AMPIL
3.
Occurrence was such that in the ordinary course of things, would not have happened if those who had control or management used
proper care
4.
Absence of explanation by defendant
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. That Dr. Ampil discharged such role is evident from the following:

He called Dr. Fuentes to perform a hysterectomy

He examined Dr. Fuentes work and found it in order

He granted Dr. Fuentes permission to leave

He ordered the closure of the incision

HOSPITAL OWNER PSI SOLIDARILY LIABLE WITH DR. AMPIL [NCC 2180], AND DIRECTLY LIABLE TO SPS. AGANAS [NCC 2176]
Previously, employers cannot be held liable for the fault or negligence of its professionals. However, this doctrine has weakened since courts came
to realize that modern hospitals are taking a more active role in supplying and regulating medical care to its patients, by employing staff of
physicians, among others. Hence, there is no reason to exempt hospitals from the universal rule of respondeat superior. Here are the Courts bases
for sustaining PSIs liability:

Ramos v. CA doctrine on E-E relationship

For purposes of apportioning responsibility in medical negligence cases, an employer-employee relationship in effect exists
between hospitals and their attending and visiting physicians. [LABOR LESSON: power to hire, fire, power of control]
Agency principle of apparent authority / agency by estoppel

Imposes liability because of the actions of a principal or employer in somehow misleading the public into believing that the
relationship or the authority exists [see NCC 1869]
PSI publicly displays in the Medical City lobby the names and specializations of their physicians. Hence, PSI 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.

o
o

If doctors do well, hospital profits financially, so when negligence mars the quality of its services, the hospital should
not be allowed to escape liability for its agents acts.
Doctrine of corporate negligence / corporate responsibility

This is the judicial answer to the problem of allocating hospitals liability for the negligent acts of health practitioners, absent
facts to support the application of respondeat superior.
This provides for the duties expected [from hospitals]. In this case, PSI failed to perform the duty of exercising reasonable care
to protect from harm all patients admitted into its facility for medical treatment. PSI failed to conduct an investigation of the matter
reported in the note of the count nurse, and this established PSIs part in the dark conspiracy of silence and concealment about
the gauzes.

PSI has actual / constructive knowledge of the matter, through the report of the attending nurses + the fact that the
operation was carried on with the assistance of various hospital staff
It also breached its duties to oversee or supervise all persons who practice medicine within its walls and take an active step in
fixing the negligence committed
PSI also liable under NCC 2180

It failed to adduce evidence to show that it exercised the diligence of a good father of the family in the accreditation and
supervision of Dr. Ampil

G.R. No. 158996 November 14, 2008

SPOUSES Fredelicto Flores (deceased) and Felicisma Flores, petitioners
vs.
SPOUSES Dominador Pineda and Virgina Saclolo, and Florencio, Candida, Marta, Godofredo, Baltazar and Lucena, all surnamed PINEDA,
as heirs of the deceased Teresita S. Pineda, and United Doctors Medical Center, Inc., respondents
FACTS
Teresita Pineda (Teresita) was a 51 y/o unmarried woman living in Sto. Domingo, Nueva Ecija
Teresita consulted her townmate, Dr. Fredelicto Flores, regarding her medical condition (general body weakness, loss of appetite,
frequent urination and thirst, and on-and-off vaginal bleeding)
Dr. Fredelicto initially interviewed the patient and asked the history of her monthly period to analyze the probable cause of the vaginal
bleeding.
Dr. Fredelicto advised the patient to return the following week or to go the United Doctors Medical Center (UDMC) in Quezon City for a
general check-up. He suspected that her other symptoms might be due to diabetes and told her to continue her medications.
Teresita did not return the next week as advised.
When her condition persisted, she went to further consult Dr. Flores at his UDMC clinic on April 28, 1987. To get there she traveled for at
least 2 hours from Nueva Ecija to Quezon City with her sister, Lucena Pineda. They arrived at UDMC at around 11:15 am.
Lucena later testified that her sister was then so weak that she had to lie down on the couch of the clinic while they waited for Dr.
Fredelicto to arrive.
When Dr. Fredelicto arrived, he did a routine check-up and ordered Teresitas admission to the hospital. In the admission slip, he directed
the hospital staff to prepare the patient for an on call D&C operation to be performed by his wife, Dr. Felicisma Flores (Dr. Felicisma).
Teresita was brought to her hospital room at around 12 noon; hospital staff took her blood and urine samples for the lab tests which Dr.
Fredelicto ordered.
Teresita was taken to the operating room at 2:40 pm of the same day. It was only then that she met Dr. Felicisma, an ob-gyn. The 2
doctors (Dr. Felicisma and Dr. Fredelicto) conferred on the patients medical condition. The resident physician and the medical intern gave
Dr. Felicisma their own briefings.
Dr. Felicisma also interviewed and conducted an internal vaginal examination of the patient which lasted for about 15 minutes.
Dr. Felicisma then called the laboratory for the results of the patients tests. At that time, only the results for the blood sugar (10.67
mmol/L), uric acid determination, cholesterol determination, and CBC (109 g/L) were available.
Based on these preparations, Dr. Felicisma proceeded with the D&C operation with Dr. Fredelicto administering the general anesthesia.
The D&C operation lasted for about 10-15 minutes. By 3:40 pm, Teresita was wheeled back to her room.
A day after the operation (April 29, 1987), Teresita was subjected to an ultrasound examination as a confirmatory procedure. Results
showed that she had an enlarged uterus and myoma uteri. Dr. Felicisma, however, advised Teresita that she could spend her recovery
period at home. Still feeling weak, Teresita opted for hospital confinement.
Teresitas complete lab exam results came only on April 29, 1987. Teresitas urinalysis showed a 3+ indicating that the sugar in her
urine was very high. She was then placed under the care of Dr. Amado Jorge, an internist.
By April 30, 1987, Teresitas condition had worsened. She experienced difficulty breathing and was rushed to the ICU. Further tests
confirmed that she was suffering from DM Type II. Insulin was administered to the patient, but the medication might have arrived too late.
Due to complications induced by diabetes, Teresita died in the morning of May 6, 1987.
ISSUES FOR RESOLUTION
Core Issue: whether the decision to proceed with the D&C operation was an honest mistake of judgment OR one amounting to negligence

The respondents claim for damages is based on their allegation that the decision of the petitioner spouses to proceed with the D&C
operation, notwithstanding Teresitas condition and lab test results, amounted to negligence.
The petitioner spouses contend that a D&C operation is the proper and accepted procedure to address vaginal bleeding the medical
problem presented to them.
Medical Negligence Case type of claim to redress a wrong committed by a medical professional that has caused bodily harm or the death of a
patient.
4 Elements in a Medical Negligence Case:
1. Duty
2. Breach
3. Injury
4. Proximate Causation
Standard of Care and Breach of Duty
D&C is the classic gynecologic procedure for the evaluation and possible therapeutic treatment for abnormal vaginal bleeding.
Expert witnesses objected to the time the D&C operation was conducted in Teresitas case. Given Teresitas blood sugar level, her
diabetic condition should have been addressed first.
The petitioner spouses contentions (at the time of the operation, there was nothing to indicate that Teresita was afflicted with diabetes;
their principal concern was to determine the cause and to stop the bleeding) missed several points:
o 1st: As early as April 17, 1987, Teresita was already suspected to be suffering from diabetes. The suspicion that she had
diabetes arose again right before the D&C operation on April 28, 1987.
o 2nd: The petitioner spouses were duly advised that the patient was experiencing all the classic symptoms of diabetes. Expert
testimonies showed that tests should have been ordered immediately on admission to the hospital in view of the symptoms
presented. Failure to recognize the existence of diabetes constitutes negligence.
o 3rd: The petitioner spouses cannot claim that their principal concern was the vaginal bleeding and should not therefore be held
accountable for complications coming from other sources. This is a very narrow and self-serving view that even reflects on their
competence.
The court finds that reasonable prudence would have shown that diabetes and its complications were foreseeable harm that should been
taken into consideration by the petitioner spouses. If a patient suffers from some disability that increases the magnitude of risk to him, that
disability must be taken into account so long as it is or should have been known to the physician. When the patient is exposed to an
increased risk, it is incumbent upon the physician to take commensurate and adequate precautions.
Vaginal bleeding is only rarely so heavy and life-threatening that urgent first aid measures are required. Medical records of Teresita failed
to indicate that there was profuse vaginal bleeding.
That the D&C operation was conducted principally to diagnose the cause of the vaginal bleeding leads the court to conclude that it is
merely an elective procedure, not an emergency case.
The prudent move would have been to address the patients hyperglycemic state immediately and promptly before any other procedure is
undertaken.
The patients hyperglycemic condition should have been managed not only before and during the operation, but also immediately
after.
Above facts point to one conclusion, that the petitioner spouses failed to comply with their duty to observe the standard of care to be
given to hyperglycemic/diabetic patients undergoing surgery.
Injury and Causation
Respondents contend that unnecessarily subjecting Teresita to a D&C operation without adequately preparing her aggravated her
hyperglycemic state and caused her untimely demise.
D&C (a form of physical stress) aggravated diabetes. Surgical stress can aggravate the patients hyperglycemia. Hyperglycemia if
prolonged and unchecked, can lead to death. The patient apparently had diabetic ketoacidosis.
The diabetic complication could have been prevented with the observance of standard medical precautions.
The D&C operation and Teresitas death due to aggravated diabetic condition is therefore sufficiently established.
DECISION
The court did not find the petition meritorious.
Both the trial and the appellate court awarded actual damages as compensation for the pecuniary loss the respondents suffered. The loss
was presented in terms of the hospital bills and expenses the respondents incurred on account of Teresitas confinement and death.
The court affirmed the award of actual damages of P36,000.00 representing the hospital expenses the patient incurred.
In addition to the award for actual damages, the respondent heirs of Teresita are likewise entitled to P50,000.00 as death indemnity
pursuant to Article 2206 of the Civil Code which states that the amount of damages for death caused by a xxx quasi-delict shall be at
least three thousand pesos, even though there may have been mitigating circumstances xxx
Moral damages are designed to compensate the claimant for the injury suffered, that is, for the mental anguish, serious anxiety, wounded
feelings which the respondents herein must have surely felt with the unexpected loss of their daughter. They affirmed the appellate courts
award of P400,000.00 by way of moral damages to the respondents.

They similarly affirmed the grant of exemplary damages. Because of the petitioner spouses negligence in subjecting Teresita to an
operation without first recognizing and addressing her diabetic condition, the appellate court awarded exemplary damages to the
respondents in the amount of P100,000.00.
We MODIFY the CA Decision by additionally granting an award of P50,000.00 as death indemnity and by reversing the deletion of the
award of attorney's fees and costs and restoring the award of P100,000.00 as attorney's fees. Costs of litigation are adjudged against
petitioner spouses.

SOLIDUM VS PEOPLE

FACTS: This appeal is taken by a physician-anesthesiologist who has been pronounced guilty of reckless
imprudence resulting in serious physical injuries by the Regional Trial Court (RTC) and the Court of Appeals (CA).
He had been part of the team of anesthesiologists during the surgical pull-through operation conducted on a threeyear old patient born with an imperforate anus.
1

The antecedents are as follows:

Gerald Albert Gercayo (Gerald) was born on June 2, 1992 with an imperforate anus. Two days after his birth,
Gerald underwent colostomy, a surgical procedure to bring one end of the large intestine out through the abdominal
wall, enabling him to excrete through a colostomy bag attached to the side of his body.
2

On May 17, 1995, Gerald, then three years old, was admitted at the Ospital ng Maynila for a pull-through
operation. Dr. Leandro Resurreccion headed the surgical team, and was assisted by Dr. Joselito Luceo, Dr.
Donatella Valea and Dr. Joseph Tibio. The anesthesiologists included Dr. Marichu Abella, Dr. Arnel Razon and
petitioner Dr. Fernando Solidum (Dr. Solidum). During the operation, Gerald experienced bradycardia, and went
into a coma. His coma lasted for two weeks, but he regained consciousness only after a month. He could no
longer see, hear or move.
5

10

11

Agitated by her sons helpless and unexpected condition, Ma. Luz Gercayo (Luz) lodged a complaint for reckless
imprudence resulting in serious physical injuries with the City Prosecutors Office of Manila against the attending
physicians.
12

Upon a finding of probable cause, the City Prosecutors Office filed an information solely against Dr.
Solidum, alleging:
13

That on or about May 17, 1995, in the City of Manila, Philippines, the said accused, being then an anesthesiologist
at the Ospital ng Maynila, Malate, this City, and as such was tasked to administer the anesthesia on three-year old
baby boy GERALD ALBERT GERCAYO, represented by his mother, MA. LUZ GERCAYO, the former having been
born with an imperforate anus [no anal opening] and was to undergo an operation for anal opening [pull through
operation], did then and there willfully, unlawfully and feloniously fail and neglect to use the care and diligence as
the best of his judgment would dictate under said circumstance, by failing to monitor and regulate properly the
levels of anesthesia administered to said GERALD ALBERT GERCAYO and using 100% halothane and other
anesthetic medications, causing as a consequence of his said carelessness and negligence, said GERALD
ALBERT GERCAYO suffered a cardiac arrest and consequently a defect called hypoxic encephalopathy meaning
insufficient oxygen supply in the brain, thereby rendering said GERALD ALBERT GERCAYO incapable of moving
his body, seeing, speaking or hearing, to his damage and prejudice.
Contrary to law.

14

The case was initially filed in the Metropolitan Trial Court of Manila, but was transferred to the RTC pursuant to
Section 5 of Republic Act No. 8369 (The Family Courts Act of 1997), where it was docketed as Criminal Case No.
01-190889.
15

Judgment of the RTC

On July 19, 2004, the RTC rendered its judgment finding Dr. Solidum guilty beyond reasonable doubt of reckless
imprudence resulting to serious physical injuries, decreeing:
16

WHEREFORE, premises considered, the Court finds accused DR. FERNANDO P. SOLIDUM GUILTY beyond
reasonable doubt as principal of the crime charged and is hereby sentenced to suffer the indeterminate penalty of
TWO (2) MONTHS and ONE (1) DAY of arresto mayor as minimum to ONE (1) YEAR, ONE (1) MONTH and TEN
(10) DAYS of prision correccional as maximum and to indemnify, jointly and severally with the Ospital ng Maynila,
Dr. Anita So and Dr. Marichu Abella, private complainant Luz Gercayo, the amount of P500,000.00 as moral
damages and P100,000.00 as exemplary damages and to pay the costs.
Accordingly, the bond posted by the accused for his provisional liberty is hereby CANCELLED.
SO ORDERED.

17

Upon motion of Dr. Anita So and Dr. Marichu Abella to reconsider their solidary liability, the RTC excluded them
from solidary liability as to the damages, modifying its decision as follows:
18

WHEREFORE, premises considered, the Court finds accused Dr. Fernando Solidum, guilty beyond reasonable
doubt as principal of the crime charged and is hereby sentenced to suffer the indeterminate penalty of two (2)
months and one (1) day of arresto mayor as minimum to one (1) year, one (1) month and ten (10) days of prision
correccional as maximum and to indemnify jointly and severally with Ospital ng Maynila, private complainant Luz
Gercayo the amount of P500,000.00 as moral damages and P100,000 as exemplary damages and to pay the
costs.
Accordingly, the bond posted by the accused for his provisional liberty is hereby cancelled.

19

Decision of the CA
On January 20, 2010, the CA affirmed the conviction of Dr. Solidum, pertinently stating and ruling:
20

The case appears to be a textbook example of res ipsa loquitur.

xxxx
x x x [P]rior to the operation, the child was evaluated and found fit to undergo a major operation. As noted by the
OSG, the accused himself testified that pre-operation tests were conducted to ensure that the child could withstand
the surgery. Except for his imperforate anus, the child was healthy. The tests and other procedures failed to reveal
that he was suffering from any known ailment or disability that could turn into a significant risk. There was not a hint
that the nature of the operation itself was a causative factor in the events that finally led to hypoxia.
In short, the lower court has been left with no reasonable hypothesis except to attribute the accident to a failure in
the proper administration of anesthesia, the gravamen of the charge in this case. The High Court elucidates in
Ramos vs. Court of Appeals 321 SCRA 584
In cases where the res ipsa loquitur is applicable, the court is permitted to find a physician negligent upon proper
proof of injury to the patient, without the aid of expert testimony, where the court from its fund of common
knowledge can determine the proper standard of care.
Where common knowledge and experience teach that a resulting injury would not have occurred to the patient if
due care had been exercised, an inference of negligence may be drawn giving rise to an application of the doctrine
of res ipsa loquitur without medical evidence, which is ordinarily required to show not only what occurred but how
and why it occurred. When the doctrine is appropriate, all that the patient must do is prove a nexus between the
particular act or omission complained of and the injury sustained while under the custody and management of the
defendant without need to produce expert medical testimony to establish the standard of care. Resort to res ipsa
loquitur is allowed because there is no other way, under usual and ordinary conditions, by which the patient can
obtain redress for injury suffered by him.

The lower court has found that such a nexus exists between the act complained of and the injury sustained, and in
line with the hornbook rules on evidence, we will afford the factual findings of a trial court the respect they deserve
in the absence of a showing of arbitrariness or disregard of material facts that might affect the disposition of the
case. People v. Paraiso 349 SCRA 335.
The res ipsa loquitur test has been known to be applied in criminal cases. Although it creates a presumption of
negligence, it need not offend due process, as long as the accused is afforded the opportunity to go forward with
his own evidence and prove that he has no criminal intent. It is in this light not inconsistent with the constitutional
presumption of innocence of an accused.
IN VIEW OF THE FOREGOING, the modified decision of the lower court is affirmed.
SO ORDERED.

21

Dr. Solidum filed a motion for reconsideration, but the CA denied his motion on May 7, 2010.

22

Hence, this appeal.

ISSUE:

THE HONORABLE COURT OF APPEALS ERRED IN APPLYING THE PRINCIPLE OF RES IPSA LOQUITOR (sic)
WHEN THE DEFENSE WAS ABLE TO PROVE THAT THERE IS NO NEGLIGENCE ON THE PART OF THE
PETITIONER, AND NO OVERDOSING IN THE APPLICATION OF THE ANESTHETIC AGENT BECAUSE THERE
WAS NO 100% HALOTHANE ADMINISTERED TO THE CHILD, BUT ONLY ONE (1%) PERCENT AND THE
APPLICATION THEREOF, WAS REGULATED BY AN ANESTHESIA MACHINE. THUS, THE APPLICATION OF
THE PRINCIPLE OF RES IPSA LOQUITOR (sic) CONTRADICTED THE ESTABLISHED FACTS AND THE LAW
APPLICABLE IN THE CASE
HELD:
The appeal is meritorious.
Applicability of the Doctrine of Res Ipsa Loquitur
Res ipsa loquitur is literally translated as "the thing or the transaction speaks for itself." The doctrine res ipsa
loquitur means that "where the thing which causes injury is shown to be under the management of the defendant,
and the accident is such as in the ordinary course of things does not happen if those who have the management
use proper care, it affords reasonable evidence, in the absence of an explanation by the defendant, that the
accident arose from want of care." It 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.
24

Hence, res ipsa loquitur is applied in conjunction with the doctrine of common knowledge."

25

Jarcia, Jr. v. People has underscored that the doctrine is not a rule of substantive law, but merely a mode of proof
or a mere procedural convenience. The doctrine, when applicable to the facts and circumstances of a given case,
is not meant to and does not dispense with the requirement of proof of culpable negligence against the party
charged. It merely determines and regulates what shall be prima facie evidence thereof, and helps the plaintiff in
proving a breach of the duty. The doctrine can be invoked when and only when, under the circumstances involved,
direct evidence is absent and not readily available.
26

27

The applicability of the doctrine of res ipsa loquitur in medical negligence cases was significantly and exhaustively
explained in Ramos v. Court of Appeals, where the Court said
28

Medical malpractice cases do not escape the application of this doctrine. Thus, res ipsa loquitur has been applied
when the circumstances attendant upon the harm are themselves of such a character as to justify an inference of
negligence as the cause of that harm. The application of res ipsa loquitur in medical negligence cases presents a
question of law since it is a judicial function to determine whether a certain set of circumstances does, as a matter
of law, permit a given inference.
Although generally, expert medical testimony is relied upon in malpractice suits to prove that a physician has done
a negligent act or that he has deviated from the standard medical procedure, when the doctrine of res ipsa loquitur
is availed by the plaintiff, the need for expert medical testimony is dispensed with because the injury itself provides
the proof of negligence. The reason is that the general rule on the necessity of expert testimony applies only to
such matters clearly within the domain of medical science, and not to matters that are within the common
knowledge of mankind which may be testified to by anyone familiar with the facts. Ordinarily, only physicians and
surgeons of skill and experience are competent to testify as to whether a patient has been treated or operated
upon with a reasonable degree of skill and care. However, testimony as to the statements and acts of physicians
and surgeons, external appearances, and manifest conditions which are observable by any one may be given by
non-expert witnesses. Hence, in cases where the res ipsa loquitur is applicable, the court is permitted to find a
physician negligent upon proper proof of injury to the patient, without the aid of expert testimony, where the court
from its fund of common knowledge can determine the proper standard of care. Where common knowledge and
experience teach that a resulting injury would not have occurred to the patient if due care had been exercised, an
inference of negligence may be drawn giving rise to an application of the doctrine of res ipsa loquitur without
medical evidence, which is ordinarily required to show not only what occurred but how and why it occurred. When
the doctrine is appropriate, all that the patient must do is prove a nexus between the particular act or omission
complained of and the injury sustained while under the custody and management of the defendant without need to
produce expert medical testimony to establish the standard of care. Resort to res ipsa loquitur is allowed because
there is no other way, under usual and ordinary conditions, by which the patient can obtain redress for injury
suffered by him.
Thus, courts of other jurisdictions have applied the doctrine in the following situations: leaving of a foreign object in
the body of the patient after an operation, injuries sustained on a healthy part of the body which was not under, or
in the area, of treatment, removal of the wrong part of the body when another part was intended, knocking out a
tooth while a patients jaw was under anesthetic for the removal of his tonsils, and loss of an eye while the patient
plaintiff was under the influence of anesthetic, during or following an operation for appendicitis, among others.
Nevertheless, despite the fact that the scope of res ipsa loquitur has been measurably enlarged, it does not
automatically apply to all cases of medical negligence as to mechanically shift the burden of proof to the defendant
to show that he is not guilty of the ascribed negligence. Res ipsa loquitur is not a rigid or ordinary doctrine to be
perfunctorily used but a rule to be cautiously applied, depending upon the circumstances of each case. It is
generally restricted to situations in malpractice cases where a layman is able to say, as a matter of common
knowledge and observation, that the consequences of professional care were not as such as would ordinarily have
followed if due care had been exercised. A distinction must be made between the failure to secure results, and the
occurrence of something more unusual and not ordinarily found if the service or treatment rendered followed the
usual procedure of those skilled in that particular practice. It must be conceded that the doctrine of res ipsa loquitur
can have no application in a suit against a physician or surgeon which involves the merits of a diagnosis or of a
scientific treatment. The physician or surgeon is not required at his peril to explain why any particular diagnosis
was not correct, or why any particular scientific treatment did not produce the desired result. Thus, res ipsa loquitur
is not available in a malpractice suit if the only showing is that the desired result of an operation or treatment was
not accomplished. The real question, therefore, is whether or not in the process of the operation any extraordinary
incident or unusual event outside of the routine performance occurred which is beyond the regular scope of
customary professional activity in such operations, which, if unexplained would themselves reasonably speak to the
average man as the negligent cause or causes of the untoward consequence. If there was such extraneous
intervention, the doctrine of res ipsa loquitur may be utilized and the defendant is called upon to explain the matter,
by evidence of exculpation, if he could.
In order to allow resort to the doctrine, therefore, the following essential requisites must first be satisfied, to wit: (1)
the accident was of a kind that does not ordinarily occur unless someone is negligent; (2) the instrumentality or
agency that caused the injury was under the exclusive control of the person charged; and (3) the injury suffered
must not have been due to any voluntary action or contribution of the person injured.
29

The Court considers the application here of the doctrine of res ipsa loquitur inappropriate. Although it should be
conceded without difficulty that the second and third elements were present, considering that the anesthetic agent
and the instruments were exclusively within the control of Dr. Solidum, and that the patient, being then unconscious
during the operation, could not have been guilty of contributory negligence, the first element was undeniably
wanting. Luz delivered Gerald to the care, custody and control of his physicians for a pull-through operation. Except
for the imperforate anus, Gerald was then of sound body and mind at the time of his submission to the physicians.
Yet, he experienced bradycardia during the operation, causing loss of his senses and rendering him immobile.
Hypoxia, or the insufficiency of oxygen supply to the brain that caused the slowing of the heart rate, scientifically
termed as bradycardia, would not ordinarily occur in the process of a pull-through operation, or during the
administration of anesthesia to the patient, but such fact alone did not prove that the negligence of any of his
attending physicians, including the anesthesiologists, had caused the injury. In fact, the anesthesiologists attending
to him had sensed in the course of the operation that the lack of oxygen could have been triggered by the vagovagal reflex, prompting them to administer atropine to the patient.
30