CASE DIGEST:
Ramon v. CA 203 SCRA 657
Source: https://lawphil.net/judjuris/juri1999/dec1999/gr_124354_1999.html
Facts:
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Erlinda Ramos, a 47-year old robust woman, was normal except for her experiencing
occasional pain due to the presence of stone in her gall bladder. She was advised to undergo
an operation for its removal. The results in the examinations she underwent indicate that
she was fit for the operation. She and her husband Rogelio met Dr. Hosaka, one of the
defendants, who advised that she should undergo cholecystectomy.
Dr. Hosaka assured them that he will get a good anaesthesiologist. At 7:30 a.m. on the day
of the operation at Delos Santos Medical Center, Herminda Cruz, Erlinda’s sister-in-law
and the dean of the College of Nursing in Capitol Medical Center, was there to provide
moral support. Dr. Perfecta Gutierrez was to administer the anaesthesia. Dr. Hosaka arrived
only at 12:15 p. m. Herminda saw Dr. Gutierrez intubating the patient, and heard the latter
say “Ang hirap ma-intubate nito, mali yata ang pagkakapasok. O, lumalaki ang tiyan.”
Herminda saw bluish discoloration of the nailbeds of the patient. She heard Dr. Hosaka
issue an order for someone to call Dr. Calderon. The doctor arrived and placed the patient
in trendelenburg position, wherein the head of the patient is positioned lower than the feet,
which indicates a decrease of blood supply in the brain. Herminda knew and told Rogelio
that something wrong was happening. Dr. Calderon was able to intubate the patient.
Erlinda was taken to the ICU and became comatose.Rogelio filed a civil case for damages.
The trial court ruled in his favor, finding Dr. Gutierrez, Dr. Hosaka, and the hospital, guilty
of negligence, but the Court of Appeals reversed the decision. Hence, petitioner filed a
Motion for Reconsideration, which the Court of Appeals denied for having been filed
beyond the reglementary period. However, it was found that the notice of the decision was
never sent to the petitioner’s counsel. Rather, it was sent to the petitioner, addressing him
as Atty. Rogelio Ramos, as if he was the legal counsel. The petitioner filed the instant
petition for certiorari. On the procedural issue, the Supreme Court rules that since the notice
did not reach the petitioner’s then legal counsel, the motion was filed on time.
Issue:
Whether a surgeon, an anaesthesiologist, and a hospital, should be made liable for the unfortunate
comatose condition of a patient scheduled for cholecystectomy.
Ruling:
Res Ipsa Loquitor
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Res ipsa loquitur is 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
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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.
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. However, much has been said that res ipsa loquitur is not a rule of
substantive law and, as such, does not create or constitute an independent or separate
ground of liability. 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.
- The accident is of a kind which ordinarily does not ccur in the absence of someone’s
negligence;
- It is caused by an instrumentality within the exclusive control of the defendant or
defendants; and
- The possibility of contributing conduct which would make the plaintiff responsible
is eliminated.
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.
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. 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. 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.
Erlinda submitted herself for cholecystectomy and expected a routine general surgery to
be performed on her gall bladder. On that fateful day she delivered her person over to the
care, custody and control of private respondents who exercised complete and exclusive
control over her. At the time of submission, Erlinda was neurologically sound and, except
for a few minor discomforts, was likewise physically fit in mind and body. However,
during the administration of anesthesia and prior to the performance of cholecystectomy
she suffered irreparable damage to her brain. Thus, without undergoing surgery, she went
out of the operating room already decerebrate and totally incapacitated. Obviously, brain
damage, which Erlinda sustained, is an injury which does not normally occur in the process
of a gall bladder operation. In fact, this kind of situation does not in the absence of
negligence of someone in the administration of anesthesia and in the use of endotracheal
tube. Furthermore, the instruments used in the administration of anesthesia, including the
endotracheal tube, were all under the exclusive control of private respondents, who are the
physicians-in-charge. Likewise, petitioner Erlinda could not have been guilty of
contributory negligence because she was under the influence of anesthetics which rendered
her unconscious.
Negligence of the Anaesthesiologist
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The pre-operative evaluation of a patient prior to the administration of anesthesia is
universally observed to lessen the possibility of anesthetic accidents. Respondent Dra.
Gutierrez’ act of seeing her patient for the first time only an hour before the scheduled
operative procedure was, therefore, an act of exceptional negligence and professional
irresponsibility.
Her failure to follow this medical procedure is, therefore, a clear indicia of her negligence.
Erlinda’s case was elective and this was known to respondent Dra. Gutierrez. Thus, she
had all the time to make a thorough evaluation of Erlinda’s case prior to the operation and
prepare her for anesthesia. However, she never saw the patient at the bedside. She herself
admitted that she had seen petitioner only in the operating room, and only on the actual
date of the cholecystectomy. She negligently failed to take advantage of this important
opportunity. As such, her attempt to exculpate herself must fail.
Negligence of the Anaesthesiologist
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The pre-operative evaluation of a patient prior to the administration of anesthesia is
universally observed to lessen the possibility of anesthetic accidents. Respondent Dra.
Gutierrez’ act of seeing her patient for the first time only an hour before the scheduled
operative procedure was, therefore, an act of exceptional negligence and professional
irresponsibility. Her failure to follow this medical procedure is, therefore, a clear indicia of
her negligence.
Erlinda’s case was elective and this was known to respondent Dra. Gutierrez. Thus, she
had all the time to make a thorough evaluation of Erlinda’s case prior to the operation and
prepare her for anesthesia. However, she never saw the patient at the bedside.
She herself admitted that she had seen petitioner only in the operating room, and only on
the actual date of the cholecystectomy. She negligently failed to take advantage of this
important opportunity. As such, her attempt to exculpate herself must fail.
Opinion of Expert Witness
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An anesthetic accident caused by a rare drug-induced bronchospasm properly falls within
the fields of anesthesia, internal medicine-allergy, and clinical pharmacology. The
resulting anoxic encephalopathy belongs to the field of neurology. While admittedly, many
bronchospastic-mediated pulmonary diseases are within the expertise of pulmonary
medicine, Dr. Jamora’s field, the anesthetic drug-induced, allergic mediated bronchospasm
alleged in this case is within the disciplines of anesthesiology, allergology and
pharmacology.
On the basis of the foregoing transcript, in which the pulmonologist himself admitted that
he could not testify about the drug with medical authority, it is clear that the appellate court
erred in giving weight to Dr. Jamora’s testimony as an expert in the administration of
Thiopental Sodium. Generally, to qualify as an expert witness, one must have acquired
special knowledge of the subject matter about which he or she is to testify, either by the
study of recognized authorities on the subject or by practical experience.
Clearly, Dr. Jamora does not qualify as an expert witness based on the above standard since
he lacks the necessary knowledge, skill, and training in the field of anesthesiology. Oddly,
apart from submitting testimony from a specialist in the wrong field, private respondents’
intentionally avoided providing testimony by competent and independent experts in the
proper areas.
Proximate Cause
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Proximate cause has been defined as that which, in natural and continuous sequence,
unbroken by any efficient intervening cause, produces injury, and without which the result
would not have occurred. An injury or damage is proximately caused by an act or a failure
to act, whenever it appears from the evidence in the case, that the act or omission played a
substantial part in bringing about or actually causing the injury or damage; and that the
injury or damage was either a direct result or a reasonably probable consequence of the act
or omission.
Instead of the intended endotracheal intubation what actually took place was an esophageal
intubation. During intubation, such distention indicates that air has entered the
gastrointestinal tract through the esophagus instead of the lungs through the trachea. Entry
into the esophagus would certainly cause some delay in oxygen delivery into the lungs as
the tube which carries oxygen is in the wrong place.
T abdominal distention had been observed during the first intubation suggests that the
length of time utilized in inserting the endotracheal tube (up to the time the tube was
withdrawn for the second attempt) was fairly significant. Due to the delay in the delivery
of oxygen in her lungs Erlinda showed signs of cyanosis.
Responsibility of the Surgeon
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As the so-called “captain of the ship,” it is the surgeon’s responsibility to see to it that those
under him perform their task in the proper manner. Respondent Dr. Hosaka’s negligence
can be found in his failure to exercise the proper authority in not determining if his
anesthesiologist observed proper anesthesia protocols.
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In fact, no evidence on record exists to show that respondent Dr. Hosaka verified if
respondent Dra. Gutierrez properly intubated the patient. Furthermore, it does not escape
us that respondent Dr. Hosaka had scheduled another procedure in a different hospital at
the same time as Erlinda’s cholecystectomy, and was in fact over three hours late for the
latter’s operation. Because of this, he had little or no time to confer with his anesthesiologist
regarding the anesthesia delivery. This indicates that he was remiss in his professional
duties towards his patient. Thus, he shares equal responsibility for the events which resulted
in Erlinda’s condition.
Responsibility of the Hospital
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Hospitals hire, fire and exercise real control over their attending and visiting "consultant"
staff. While "consultants" are not, technically employees, a point which respondent
hospital asserts in denying all responsibility for the patient's condition, the control
exercised, the hiring, and the right to terminate consultants all fulfill the important
hallmarks of an employer-employee relationship, with the exception of the payment of
wages. In assessing whether such a relationship in fact exists, the control test is
determining.
Accordingly, on the basis of the foregoing, we rule that for the purpose of allocating
responsibility in medical negligence cases, an employer-employee relationship in effect
exists between hospitals and their attending and visiting physicians.
The basis for holding an employer solidarily responsible for the negligence of its employee
is found in Article 2180 of the Civil Code which considers a person accountable not only
for his own acts but also for those of others based on the former's responsibility under a
relationship of patria potestas. Such responsibility ceases when the persons or entity
concerned prove that they have observed the diligence of a good father of the family to
prevent damage. In the instant case, respondent hospital, apart from a general denial of its
responsibility over respondent physicians, failed to adduce evidence showing that it
exercised the diligence of a good father of a family in the hiring and supervision of the
latter.
It failed to adduce evidence with regard to the degree of supervision which it exercised
over its physicians. In neglecting to offer such proof, or proof of a similar nature,
respondent hospital thereby failed to discharge its burden under the last paragraph of
Article 2180. Having failed to do this, respondent hospital is consequently solidarily
responsible with its physicians for Erlinda's condition.
Damages
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At current levels, the P8000/monthly amount established by the trial court at the time of its
decision would be grossly inadequate to cover the actual costs of home-based care for a
comatose individual. The calculated amount was not even arrived at by looking at the actual
cost of proper hospice care for the patient.
What it reflected were the actual expenses incurred and proved by the petitioners after they
were forced to bring home the patient to avoid mounting hospital bills. And yet ideally, a
comatose patient should remain in a hospital or be transferred to a hospice specializing in
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the care of the chronically ill for the purpose of providing a proper milieu adequate to meet
minimum standards of care. Given these considerations, the amount of actual damages
recoverable in suits arising from negligence should at least reflect the correct minimum
cost of proper care, not the cost of the care the family is usually compelled to undertake at
home to avoid bankruptcy.
Our rules on actual or compensatory damages generally assume that at the time of
litigation, the injury suffered as a consequence of an act of negligence has been completed
and that the cost can be liquidated. However, these provisions neglect to take into account
those situations, as in this case, where the resulting injury might be continuing and possible
future complications directly arising from the injury, while certain to occur, are difficult to
predict. Temperate damages can and should be awarded on top of actual or compensatory
damages in instances where the injury is chronic and continuing. And because of the unique
nature of such cases, no incompatibility arises when both actual and temperate damages
are provided for.
The reason is that these damages cover two distinct phases. As it would not be equitable –
and certainly not in the best interests of the administration of justice – for the victim in
such cases to constantly come before the courts and invoke their aid in seeking adjustments
to the compensatory damages previously awarded – temperate damages are appropriate.
The amount given as temperate damages, though to a certain extent speculative, should
take into account the cost of proper care. In the instant case, petitioners were able to provide
only home-based nursing care for a comatose patient who has remained in that condition
for over a decade.
Having premised our award for compensatory damages on the amount provided by
petitioners at the onset of litigation, it would be now much more in step with the interests
of justice if the value awarded for temperate damages would allow petitioners to provide
optimal care for their loved one in a facility which generally specializes in such care. They
should not be compelled by dire circumstances to provide substandard care at home without
the aid of professionals, for anything less would be grossly inadequate. Under the
circumstances, an award of P1,500,000.00 in temperate damages would therefore be
reasonable.
Petitioner Erlinda Ramos was in her mid-forties when the incident occurred. She has been
in a comatose state for over fourteen years now. The burden of care has so far been
heroically shouldered by her husband and children, who, in the intervening years have been
deprived of the love of a wife and a mother. Meanwhile, the actual physical, emotional and
financial cost of the care of petitioner would be virtually impossible to quantify.
Even the temperate damages herein awarded would be inadequate if petitioner’s condition
remains unchanged for the next ten years. The husband and the children, all petitioners in
this case, will have to live with the day to day uncertainty of the patient’s illness, knowing
any hope of recovery is close to nil.
They have fashioned their daily lives around the nursing care of petitioner, altering their
long term goals to take into account their life with a comatose patient. They, not the
respondents, are charged with the moral responsibility of the care of the victim. The
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family’s moral injury and suffering in this case is clearly a real one. For the foregoing
reasons, an award of P2,000,000.00 in moral damages would be appropriate.
Finally, by way of example, exemplary damages in the amount of P100,000.00 are hereby
awarded. Considering the length and nature of the instant suit we are of the opinion that
attorney’s fees valued at P100,000.00 are likewise proper.
The decision and resolution of the appellate court appealed from are hereby modified so as
to award in favor of petitioners, and solidarily against private respondents the following:
1) P1,352,000.00 as actual damages computed as of the date of promulgation of this
decision plus a monthly payment of P8,000.00 up to the time that petitioner Erlinda Ramos
expires or miraculously survives; 2) P2,000,000.00 as moral damages, 3) P1,500,000.00 as
temperate damages; 4) P100,000.00 each as exemplary damages and attorney’s fees; and,
5) the costs of the suit.