Professional Services vs.

Agana
GR No. 126297
Topic: Negligence Standard of Conduct Medical Professionals
Facts:
Natividad Agana was rushed to Medical City Hospital 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
Natividad. He found that the malignancy in her sigmoid area had spread on her left
ovary, necessitating the removal of certain portions. Dr. Ampil obtained the consent
of Natividads husband, Enrique Agana, to permit Dr. Juan Fuentes, to perform
hysterectomy on her.
After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed
the operation and closed the incision. However, the operation appeared to be
flawed. In the Record of Operation, the attending nurses remarked 2 sponges were
missing despite diligent search.

Natividad and her husband sued Professional Services, Inc. (PSI), owner of the
Medical City Hospital, Dr. Ampil, and Dr. Fuentes. They alleged that the latter are
liable for negligence for leaving two pieces of gauze inside Natividads body and
malpractice for concealing their acts of negligence.
Meanwhile, Enrique Agana also filed with the Professional Regulation Commission
(PRC) an administrative complaint for gross negligence and malpractice against Dr.
Ampil and Dr. Fuentes.
Pending the outcome of the cases, Natividad died and was duly substituted by her
above-named children (the Aganas).
Issue:
Was Dr. Ampil negligent in his operation? Can Dr. Fuentes also be held for
negligence under res ipsa loquitur?
Held & Rationale:
Ampil was negligent but Fuentes was absolved.

Natividad was released but after a couple of days she complained of excruciating
pain in her anal region. She consulted both Dr. Ampil and Dr. Fuentes about it. They
told her that the pain was the natural consequence of the surgery. Dr. Ampil then
recommended that she consult an oncologist to examine the cancerous nodes
which were not removed during the operation.
Natividad went to the US for further treatment. After four months Natividad was told
she was free of cancer. Natividad returned but was still suffering from pains. Two
weeks thereafter, her daughter found a piece of gauze protruding from her vagina.
Dr. Ampil went to her house where he extracted by hand a piece of gauze
measuring 1.5 inches in width. He then assured her that the pains would soon
vanish.
Instead, the pains intensified, prompting Natividad to seek treatment at the
Polymedic General Hospital. Dr. Gutierrez detected a foul-smelling gauze
measuring 1.5 inches in width in her vagina which badly infected her vaginal vault. A
recto-vaginal fistula had formed in her reproductive organs which forced stool to
excrete through the vagina. Natividad underwent another surgery.

The removal of all sponges used is part of a surgical operation. When a

physician or surgeon fails to remove a sponge he has placed in his patients body
that should be removed as part of the operation, he thereby leaves his operation
uncompleted. Ampil created a new condition which imposed the legal duty of calling
the new condition to his patients attention.
Ampil did not inform Natividad about the missing two pieces of gauze. Worse, he
even misled her that the pain she was experiencing was the ordinary consequence
of her operation. Had he been more candid, Natividad could have taken the
immediate and appropriate medical remedy to remove the gauzes from her body.
What was initially an act of negligence by Dr. Ampil has ripened into a deliberate
wrongful act of deceiving his patient.
This is a clear case of medical malpractice or more appropriately, medical
negligence. To successfully pursue this kind of case, a patient must only
prove that a health care provider either failed to do something which a
reasonably prudent health care provider would have done, or that he did
something that a reasonably prudent provider would not have done; and that
failure or action caused injury to the patient. Simply put, the elements are

duty, breach, injury and proximate causation. Dr, Ampil, as the lead surgeon,
had the duty to remove all foreign objects, such as gauzes, from Natividads body
before closure of the incision. When he failed to do so, it was his duty to inform
Natividad about it. Dr. Ampil breached both duties. Such breach caused injury to
Natividad, necessitating her further examination by American doctors and another
surgery. Dr. Ampils negligence is the proximate cause of Natividads injury because
he closed the incision despite the attending nurses remark that two pieces of gauze
were still missing. That they were later on extracted from Natividads vagina
established the causal link between Dr. Ampils negligence and the injury. His
deliberate concealment of the missing gauzes from the knowledge of Natividad and
her family further aggravated the injury.
Literally, res ipsa loquitur means "the thing speaks for itself." It is 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
plaintiffs prima facie case, and present a question of fact for defendant to meet with
an explanation. Stated differently, where the thing which caused the injury, without
the fault of the injured, is under the exclusive control of the defendant and the injury
is such that it should not have occurred if he, having such control used proper care,
it affords reasonable evidence, in the absence of explanation that the injury arose
from the defendants want of care, and the burden of proof is shifted to him to
establish that he has observed due care and diligence.

longer in the operating room and had, in fact, left the hospital when the injury
happened.
Under the "Captain of the Ship" rule, the operating surgeon is the person in
complete charge of the surgery room and all personnel connected with the
operation. Their duty is to obey his orders. Dr. Ampil was the lead surgeon. He
was the "Captain of the Ship." That he discharged such role is evident from his
following conduct: (1) calling Dr. Fuentes to perform a hysterectomy; (2) examining
the work of Dr. Fuentes and finding it in order; (3) granting Dr. Fuentes permission
to leave; and (4) ordering the closure of the incision. The closure of the incision
notwithstanding two pieces of gauze remained unaccounted for, caused injury to
Natividads body. Clearly, the control and management of the thing which
caused the injury was in the hands of Dr. Ampil, not Dr. Fuentes.
In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence,
does not per se create or constitute an independent or separate ground of
liability, being a mere evidentiary rule. In other words, mere invocation and
application of the doctrine does not dispense with the requirement of proof of
negligence. Here, the negligence was proven to have been committed by Dr. Ampil
and not by Dr. Fuentes.
Note:

From the foregoing statements of the rule, the requisites for the applicability
of the doctrine of res ipsa loquitur are: (1) the occurrence of an injury; (2) the
thing which caused the injury was under the control and management of the
defendant; (3) the occurrence was such that in the ordinary course of things,
would not have happened if those who had control or management used
proper care; and (4) the absence of explanation by the defendant. Of the
foregoing requisites, the most instrumental is the control and management
of the thing which caused the injury.
The element of "control and management of the thing which caused the
injury" is lacking. Hence, the doctrine of res ipsa loquitur will not apply.

The rest of the case talked about corporate negligence. I didnt include since we are
focusing on medical professionals. Anyway, the difference of this case to Cruz vs.
CA is that the doctors negligence seems to have been proved. The case doesnt
say if witness testimony was offered so perhaps its safe to assume to say maybe
there was.
If not, then the negligence is not so much on the operation, since it was a success.
But it would lie on the failure to search for the missing gauzes. And to make it worse,
is the misleading action of not telling about that failure to the patient.
Standard of conduct here applies to the captain rule.

Dr. Ampil was the lead surgeon. Dr. Fuentes assistance was only for hysterectomy.
Dr. Fuentes performed the surgery and showed his work to Dr. Ampil. The latter
examined it and finding everything to be in order, allowed Dr. Fuentes to leave the
operating room. Dr. Ampil then resumed operating on Natividad. Dr. Fuentes was no