Aquino vs. Heirs of Calayag

A physician or surgeon is liable for medical malpractice upon proof of four elements: (1) duty, (2) breach, (3) injury, and (4) proximate causation. The surgeon in charge cannot evade liability by shifting blame to the anesthesiologist when she allowed a sick anesthesiologist to participate in the operation and failed to ensure proper monitoring of the patient's vital signs. A hospital owner is not liable for the negligence of independent physicians who merely use the hospital's facilities, absent an employer-employee relationship or the presence of the two factors of ostensible agency: (1) the hospital acted in a manner leading a reasonable person to believe the physician was its agent or employee, and (2) the patient relied on such belief.

The respondents are the heirs of Raymunda Calayag, who died after a caesarean section performed at Sacred Heart Hospital (SHH), owned and operated by petitioner Dr. Alberto Reyes. The attending surgeon was petitioner Dr. Divinia Unite, who owned and operated St. Michael's Clinic where Raymunda was initially examined, and the anesthesiologist was petitioner Dr. Eduardo Aquino. The case involves the application of medical malpractice principles — a form of negligence consisting of a physician's failure to apply the degree of care and skill that the profession generally employs under similar circumstances — and the extent of a hospital owner's vicarious liability for the acts of independent physicians using hospital facilities.

When his wife Raymunda went into labor pains and began bleeding on November 13, 1990, respondent Rodrigo Calayag brought her to St. Michael's Clinic of petitioner Dr. Divinia Unite at Malolos, Bulacan. After initial examination, Dr. Unite told Rodrigo that Raymunda needed a caesarean section, but this had to be done at the better-equipped Sacred Heart Hospital (SHH), owned and operated by petitioner Dr. Alberto Reyes. SHH admitted Raymunda at 2:16 p.m. of the same day. To prepare her, the attending anesthesiologist, petitioner Dr. Eduardo Aquino, injected her at about 2:30 p.m. with a preliminary "Hipnotic," and at 2:48 p.m. administered anesthesia on her spine. A few minutes later, at 2:53 p.m., Dr. Unite delivered a stillborn eight-month-old baby. At around 3:00 p.m., the operating team noticed that Raymunda had become cyanotic — her blood darkened for lack of oxygen and, all of a sudden, her vital signs were gone. The team worked on her for about 5 to 7 minutes until these were restored.

Rodrigo claimed that when he saw Raymunda after the operation, her skin appeared dark and the white of her eyes showed. When he asked Dr. Unite why his wife did not look well, she replied that this was merely the effect of the anesthesia and that she would regain consciousness in about eight hours. When Raymunda's condition did not improve after a day, Dr. Unite referred her to Dr. Farinas, an internist, who found that she suffered a cardiac arrest during the operation, which explained her comatose state. Dr. Farinas referred Raymunda to a neurologist who advised Rodrigo to move her to a better-equipped hospital. SHH discharged her on November 16, 1990, four days after her admission.

Raymunda was directly moved to Medical Center Manila (MCM), where Dr. Rogelio Libarnes, a neurologist, examined her. He found Raymunda in a "vegetative state," having suffered from an anoxic injury due to cardio-respiratory arrest during operation. Dr. Libarnes was reluctant to further proceed without consulting Dr. Unite and Dr. Aquino. On November 23, 1990, Dr. Unite went to MCM to remove the stitches from Raymunda's surgical wound, noting that the wound had dried with slight lochial discharge. Later that day, however, Raymunda's wound split open, causing part of her intestines to jut out. MCM's Dr. Benito Chua re-sutured the wound. Raymunda never regained consciousness, prompting her MCM doctors to advise Rodrigo to take her home since they could do no more to improve her condition. MCM discharged her on November 30, 1990, and she died 15 days later on December 14, 1990.

Rodrigo filed, together with his seven children, a complaint for damages against Dr. Unite, Dr. Aquino, and Dr. Reyes before the RTC of Malolos, claiming that Dr. Unite and Dr. Aquino failed to exercise the diligence required for operating on Raymunda, and that Dr. Reyes was negligent in supervising their work. The defendant doctors uniformly denied the charge of negligence, claiming that they exercised the diligence required of them and that causes other than negligence brought about Raymunda's condition.

To prove negligence, Rodrigo presented Dr. Libarnes, who explained that cyanosis or lack of oxygen in the brain caused Raymunda's vegetative state, and that the arrest could be traced to the anesthetic accident resulting from Dr. Aquino's administration of anesthesia. Dr. Libarnes also blamed the operating doctors for not properly keeping track of Raymunda's vital signs during the procedure, resulting in their failure to promptly address the cyanosis. Dr. Chua testified that Raymunda's surgical wound would not have split open if it had been properly closed. For their defense, Dr. Unite and Dr. Aquino presented Dr. Reyes, who testified that the cardio-respiratory arrest could have been caused by factors other than high spinal anesthesia, such as sudden release of intra-abdominal pressure and amniotic fluid embolism, and that poor nutrition and medication contributed to the wound dehiscence.

• Disclaiming Responsibility (Dr. Unite): Dr. Unite washed her hands of any responsibility in Raymunda's operation, claiming that it was not her suturing that caused the splitting open of the patient's surgical wound, and that although some negligence may have attended the operation, this could be traced to the anesthesiologist, Dr. Aquino.
• Insufficient Evidence (Dr. Aquino): Dr. Aquino claimed that the evidence was insufficient to support the conclusion that anesthetic accident caused the cardio-respiratory arrest since, as testified, other factors may have caused the same.
• Lack of Employer-Employee Relationship (Dr. Reyes): Dr. Reyes claimed that he cannot be held liable for Raymunda's death since Dr. Unite and Dr. Aquino were not his employees; based on the control test, he did not exercise control and supervision over their work, as they merely used his hospital's facilities for the operation.

• Negligence of the Doctors: Rodrigo claimed that Dr. Unite and Dr. Aquino failed to exercise the diligence required for operating on Raymunda, and that Dr. Reyes was negligent in supervising their work.
• Proximate Causation: The respondents presented expert testimony from Dr. Libarnes and Dr. Chua establishing that the anesthetic accident caused the cardio-respiratory arrest, that the doctors failed to properly monitor Raymunda's vital signs, and that the wound would not have split open if properly closed.

• Negligence of the Surgeon and Anesthesiologist: Whether Dr. Unite (the surgeon) and Dr. Aquino (the anesthesiologist) acted negligently in handling Raymunda's operation, resulting in her death.
• Liability of the Hospital Owner: Whether Dr. Reyes is liable, as hospital owner, for the negligence of Dr. Unite and Dr. Aquino.

• Negligence of the Surgeon and Anesthesiologist: Yes. Dr. Unite and Dr. Aquino were negligent in handling Raymunda's operation. The elements of medical malpractice — duty, breach, injury, and proximate causation — were established through the expert testimony of Dr. Libarnes, whose credibility was preferred over that of Dr. Reyes, a co-defendant with natural bias.
• Liability of the Hospital Owner: No. Dr. Reyes cannot be held liable for Raymunda's death because there was no employer-employee relationship between him and the attending doctors, and the doctrine of ostensible agency does not apply absent evidence that the hospital acted to lead the patient to believe the doctors were its employees and that the patient relied on such belief.

• Negligence of the Surgeon and Anesthesiologist: The cause of action against the doctors is medical malpractice, a form of negligence consisting of the physician or surgeon's failure to apply to his practice that degree of care and skill that the profession generally and ordinarily employs under similar conditions and circumstances. To successfully mount a medical malpractice action, the plaintiff must establish four things: (1) duty; (2) breach; (3) injury; and (4) proximate causation. The evidence must show that the physician either failed to do something a reasonably prudent physician would have done, or did something a reasonably prudent physician would not have done, and that the failure or action caused injury to the patient. Here, Dr. Libarnes, a neurologist with expertise in the human nervous system, explained that Raymunda's vegetative state resulted from anoxic injury due to cardio-respiratory arrest during the caesarean section, which could be traced to an anesthetic accident. Dr. Aquino administered a high spinal anesthesia when he should have given only a low or mid-spinal anesthesia. Dr. Libarnes also testified that the damage could have been averted had the attending doctors promptly detected the situation and resuscitated her on time. The Court found Dr. Reyes's testimony less credible because, as a co-defendant, he had a natural bias, and since he had no opportunity to actually examine Raymunda, he could only invoke textbook medical principles that he could not clearly relate to the patient's specific condition. Dr. Unite could not exempt herself from liability because Dr. Aquino was not feeling well on the day of the operation and was in fact on sick leave; as surgeon in charge, she should not have allowed him to take part in the operation. Moreover, the record of the operation contained no notation of when Raymunda had a cardio-respiratory arrest, an important entry whose absence is itself a ground for malpractice, implying that the surgeons had no inkling when the arrest occurred and how much time they had left to revive the patient.
• Liability of the Hospital Owner: There was no concrete proof that Dr. Unite and Dr. Aquino were under the hospital's payroll. Dr. Aquino appeared to be a government physician connected with the Integrated Provincial Health Office of Bulacan, and Dr. Unite appeared to be a self-employed doctor. The hospital allowed these doctors to operate on their patients, using its operating room and assisting staff for a fee. No evidence was presented that Raymunda suffered her fate because of defective hospital facilities or poor staff support. The fact that Dr. Reyes and his wife rushed to the operating room when Raymunda's vital signs ceased did not prove that they exercised supervision over the conduct of the operation. The doctrine of ostensible agency or apparent authority requires two factors: (1) the hospital acted in a manner which would lead a reasonable person to believe that the person claimed to be negligent was its agent or employee; and (2) the patient relied on such belief. Here, there was no evidence that the hospital acted in a way that made Raymunda and her husband believe that the two doctors were in the hospital's employ. Indeed, the couple had been consulting Dr. Unite at St. Michael's Clinic, which she owned and operated, and she convinced them that the caesarean section had to be performed at SHH because it had the facilities that such operation required. If damages were allowed against the hospital under this arrangement, independently licensed surgeons would be unreasonably denied access to properly-equipped operating rooms in big hospitals.

• Medical Malpractice — A form of negligence consisting of the physician or surgeon's failure to apply to his practice that degree of care and skill that the profession generally and ordinarily employs under similar conditions and circumstances. The plaintiff must establish four elements: (1) duty — the physician has the duty to use at least the same level of care that any other reasonably competent physician would use to treat the condition under similar circumstances; (2) breach — there is breach of duty of care, skill, and diligence, or the improper performance of such duty, when the patient is injured in body or health; (3) injury — the patient suffered harm; and (4) proximate causation — the injury for which recovery is sought must be the legitimate consequence of the wrong done, with the connection between the negligence and the injury being a direct and natural sequence of events, unbroken by intervening efficient causes. The Court applied this doctrine in finding Dr. Unite and Dr. Aquino liable, relying on expert testimony to establish each element.
• Ostensible Agency or Apparent Authority — A doctrine that may make a hospital liable for the negligence of a physician who is not its employee. Two factors must be present: (1) the hospital acted in a manner which would lead a reasonable person to believe that the person claimed to be negligent was its agent or employee; and (2) the patient relied on such belief. The Court held that this doctrine did not apply because there was no evidence that the hospital acted to lead the patient to believe the doctors were its employees, and the patient had been consulting Dr. Unite at her own clinic before being convinced to use the hospital's facilities.
• Control Test — A test for determining employer-employee relationship based on whether the employer exercises control and supervision over the work of the alleged employee. The Court applied this test in determining that Dr. Reyes did not exercise control and supervision over the work of Dr. Unite and Dr. Aquino, who merely used the hospital's facilities for the operation.

• "The cause of action against the doctors in these cases is commonly known as medical malpractice. It is a form of negligence which consists in the physician or surgeon's failure to apply to his practice that degree of care and skill that the profession generally and ordinarily employs under similar conditions and circumstances." — This passage defines the controlling doctrine of medical malpractice and establishes the standard of care against which the physicians' conduct was measured.
• "To successfully mount a medical malpractice action, the plaintiff should establish four basic things: (1) duty; (2) breach; (3) injury; and (4) proximate causation." — This passage articulates the canonical four-element test for medical malpractice, which is the ratio decidendi of the Court's ruling against the surgeon and anesthesiologist.
• "Nor would the doctrine of ostensible agency or doctrine of apparent authority make Dr. Reyes liable to Raymunda's heirs for her death. Two factors must be present under this doctrine: 1) the hospital acted in a manner which would lead a reasonable person to believe that the person claimed to be negligent was its agent or employee; and 2) the patient relied on such belief." — This passage states the two-factor test for ostensible agency and explains why the hospital owner was absolved from liability.
• "If the Court were to allow damages against the hospital under this arrangement, independently licensed surgeons would be unreasonably denied access to properly-equipped operating rooms in big hospitals." — This passage articulates the policy rationale for not extending hospital liability to independent physicians who merely use hospital facilities.

• Cayao-Lasam vs. Ramolete, G.R. No. 159132, December 18, 2008, 574 SCRA 439 — Cited as authority for the definition of medical malpractice as a form of negligence consisting of the physician's failure to apply the degree of care and skill that the profession generally employs under similar circumstances.
• Lucas vs. Tuaño, G.R. No. 178763, April 21, 2009, 586 SCRA 173 — Cited for the proposition that the Court seeks guidance from expert testimonies in determining whether a defendant in a medical malpractice case exercised the required degree of care and diligence, and for the explanation of the four elements of medical malpractice.
• Li vs. Spouses Soliman, G.R. No. 165279, June 7, 2011, 651 SCRA 32 — Cited for the recognition that physicians have extraordinary technical skills that laymen do not have, which is the basis for relying on expert testimony in medical malpractice cases.
• Garcia-Rueda vs. Pascasio, 344 Phil. 323 (1997) — Cited for the proposition that the evidence in a medical malpractice case should show that the physician either failed to do something a reasonably prudent physician would have done, or did something a reasonably prudent physician would not have done, and that the failure or action caused injury to the patient.
• People vs. Lusabio, Jr., G.R. No. 186119, October 27, 2009, 604 SCRA 565 — Cited for the definition of witness bias: a witness is biased when his relation to the cause or to the parties is such that he has an incentive to exaggerate or give false color to his statements, or to suppress or pervert the truth; applied to discredit Dr. Reyes's testimony as a co-defendant.
• Flores vs. Pineda, G.R. No. 158996, November 14, 2008, 571 SCRA 83 — Cited as precedent for awarding P50,000.00 as death indemnity to the heirs of the deceased pursuant to Article 2206 of the Civil Code.

• Article 2206, Civil Code — Provides for the right of the heirs of a deceased person to recover death indemnity. The Court applied this provision in modifying the Court of Appeals decision to award the heirs of Raymunda Calayag P50,000.00 as death indemnity, in addition to the damages previously awarded.

Velasco, Jr. (Chairperson), Peralta, Mendoza, and Perlas-Bernabe, JJ., concurred.

N/A — No dissenting opinions were noted in the provided case text.