Cayao-Lasam vs. Ramolete

In medical malpractice cases, expert testimony is essential to establish both the reasonable level of care and breach thereof, as well as the causation of injury, and where the patient's own omission — not the physician's act — is the proximate cause of the injury, no damages may be recovered. Additionally, the PRC is covered by Rule 43 of the Rules of Court as a quasi-judicial agency, the enumeration in Section 1 being non-exclusive.

Dr. Fe Cayao-Lasam (petitioner) is a physician who treated Editha Ramolete (Editha) at the Lorma Medical Center in San Fernando, La Union. The Ramolete spouses (respondents) filed an administrative complaint for gross negligence and malpractice against petitioner before the Professional Regulations Commission (PRC) after Editha underwent a hysterectomy following a ruptured uterus. The case also involves the procedural question of the proper appellate remedy from PRC decisions and whether the PRC falls within the coverage of Rule 43 of the Rules of Court, which governs appeals from quasi-judicial agencies to the Court of Appeals.

On July 28, 1994, Editha Ramolete, three months pregnant, was brought to the Lorma Medical Center (LMC) in San Fernando, La Union due to vaginal bleeding. Upon advice of petitioner Dr. Fe Cayao-Lasam relayed via telephone, Editha was admitted to the LMC on the same day. A pelvic sonogram was conducted revealing the fetus' weak cardiac pulsation. The following day, a repeat pelvic sonogram showed that aside from the fetus' weak cardiac pulsation, no fetal movement was appreciated. Due to persistent and profuse vaginal bleeding, petitioner advised Editha to undergo a Dilatation and Curettage Procedure (D&C) or "raspa."

On July 30, 1994, petitioner performed the D&C procedure. Editha was discharged from the hospital the following day. Petitioner advised Editha to return for check-up on August 5, 1994, which the latter failed to do. According to petitioner, she was vocal in the operating room about not being able to see an abortus, but taking Editha's words that she was passing out some meaty mass and clotted blood, she assumed the abortus must have been expelled in the process of bleeding. Petitioner also stated that it was Editha who insisted on being discharged.

On September 16, 1994, Editha was again brought to the LMC, suffering from vomiting and severe abdominal pains. She was attended by Dr. Beatriz de la Cruz, Dr. Victor B. Mayo, and Dr. Juan V. Komiya. Dr. Mayo allegedly informed Editha that there was a dead fetus in her womb. After Editha underwent laparotomy, she was found to have a massive intra-abdominal hemorrhage and a ruptured uterus. Editha had to undergo a hysterectomy, and as a result, she lost all chance to bear a child.

On November 7, 1994, Editha and her husband Claro Ramolete filed a complaint for gross negligence and malpractice against petitioner before the PRC. Respondents alleged that Editha's hysterectomy was caused by petitioner's unmitigated negligence and professional incompetence in conducting the D&C procedure and her failure to remove the fetus inside Editha's womb. Among the alleged acts of negligence were petitioner's failure to visit or administer medication on Editha during her first day of confinement, her recommendation of a D&C procedure without conducting any internal examination prior to the procedure, and her immediate suggestion of a D&C procedure instead of closely monitoring the state of pregnancy. Petitioner denied the allegations, explaining that she had given telephone orders for Editha's medication upon confirmation of admission, visited Editha on the morning of July 28, 1994 during her rounds, performed internal examinations on July 29 and 30, 1994 which revealed Editha's cervix was open, and that respondents had consented to the D&C procedure. Petitioner further contended that Editha's condition was caused by an extremely rare case of placenta increta, and that Editha's own insistence on being discharged against medical advice and her failure to return for follow-up check-up contributed to her life-threatening condition.

The Board of Medicine, on March 4, 1999, exonerated petitioner, finding that Editha's condition was a case of Ectopic Pregnancy Interstitial, that petitioner could not be faulted for failing to detect it because the sonogram did not specify the fetus's location, and that the D&C was necessary considering Editha's open cervix and profuse bleeding. The PRC, on November 22, 2000, reversed the Board's findings and revoked petitioner's license to practice medicine. Petitioner elevated the matter to the Court of Appeals, which dismissed the petition on the ground that the PRC was not among the quasi-judicial agencies enumerated in Rule 43 and that the proper remedy was an appeal to the Office of the President.

• Rule 43 Coverage: Petitioner argued that the PRC should not be excluded from the purview of Rule 43 merely because it is not expressly mentioned in the enumeration, as Rule 43 was formulated to provide a uniform rule of appellate procedure for quasi-judicial agencies.
• Availability of Certiorari: Petitioner contended that even assuming the PRC was excluded from Rule 43, she was not precluded from filing a petition for certiorari under Rule 65 where the PRC decision was issued in excess of or without jurisdiction, or was a patent nullity.
• Complainant's Right to Appeal: Petitioner maintained that respondents were not allowed by law to appeal from the decision of the Board of Medicine to the PRC, invoking Article IV, Section 35 of the Rules and Regulations Governing the Regulation and Practice of Professionals, which she read as allowing only the respondent in an administrative case to appeal as a matter of right, while the complainant may appeal only when allowed by law. She posited that the reason was double jeopardy, since revocation of a license to practice is penal in nature.
• Due Process Violation: Petitioner asserted that her constitutional right to due process was violated because she was never informed by either respondents or the PRC that an appeal was pending before the PRC, and that the Memorandum on Appeal filed by respondents did not attach the actual registry receipt as proof of service.
• Lack of Expert Testimony: Petitioner argued that the PRC committed grave abuse of discretion in revoking her license without any expert testimony to support its conclusion as to the cause of Editha's injury, and in totally disregarding the findings of the Board of Medicine and the testimony of expert witness Dr. Augusto Manalo.
• PRC Findings Contrary to Evidence: Petitioner contended that the PRC committed grave abuse of discretion in making conclusions of fact that were not only unsupported by evidence but were actually contrary to the evidence on record.

• Proof of Service: Respondents argued that if the original registry receipt was not attached to the Memorandum on Appeal, the PRC would not have entertained the appeal or accepted the pleading for lack of notice or proof of service on the other party.
• Registry Receipt Already Appended: Respondents averred that the registry receipt could not be appended to the copy furnished to petitioner's former counsel because it was already appended to the original copy of the Memorandum on Appeal filed with the PRC.

• Complainant's Right to Appeal: Whether complainants in an administrative case before the Board of Medicine are allowed by law to appeal to the PRC from the Board's decision.
• Rule 43 Coverage: Whether the PRC is covered by Rule 43 of the Rules of Court despite not being expressly enumerated therein.
• Expert Testimony Requirement: Whether the PRC validly revoked petitioner's license absent expert testimony to support its conclusion as to the cause of Editha's injury.
• Proximate Cause: Whether the D&C procedure performed by petitioner was the proximate cause of the rupture of Editha's uterus and her subsequent hysterectomy.
• Due Process: Whether petitioner's right to due process was violated by the PRC proceedings on appeal.

• Complainant's Right to Appeal: Yes. Complainants are allowed to appeal from the decision of the Board of Medicine to the PRC, as the amended Section 35 of the Rules and Regulations Governing the Regulation and Practice of Professionals expressly grants the right to appeal to both complainants and respondents.
• Rule 43 Coverage: Yes. The PRC is covered by Rule 43 of the Rules of Court, the phrase "among these agencies" in Section 1 rendering the enumeration non-exclusive, and B.P. Blg. 129 having conferred upon the Court of Appeals exclusive appellate jurisdiction over appeals from decisions of the PRC.
• Expert Testimony Requirement: No. The PRC's revocation of petitioner's license was not supported by expert testimony, while petitioner presented the testimony of Dr. Augusto Manalo, an expert in gynecology and obstetrics, who established that the D&C procedure was not the proximate cause of Editha's injury.
• Proximate Cause: No. The D&C procedure was not the proximate cause of the rupture of Editha's uterus; the instrument used in curettage could not reach the site of an interstitial ectopic pregnancy, and Editha's own failure to return for follow-up check-up as advised was the proximate cause of her injury.
• Due Process: Yes. Petitioner's right to due process was violated because respondents failed to prove service of the Memorandum on Appeal upon petitioner, rendering the PRC proceedings null and void.

• Complainant's Right to Appeal: Petitioner invoked Article IV, Section 35 of the Rules and Regulations Governing the Regulation and Practice of Professionals, which originally provided that the respondent may appeal the decision of the Board to the Commission, while the complainant may interpose an appeal only "when allowed by law." Petitioner argued that double jeopardy principles precluded allowing complainants to appeal, since revocation of a license to practice is penal in nature. The Court rejected this argument, holding that double jeopardy attaches only in criminal cases — not administrative proceedings — as the required elements (valid indictment, competent court, arraignment, valid plea, acquittal or conviction) were absent. The Court further noted that Section 35 was subsequently amended by Resolution 174, Series of 1990, to read that "the complainant/respondent may appeal," thereby expressly granting the right to appeal to both parties. This was bolstered by PRC Resolution No. 06-342(A), the New Rules of Procedure, which provides that "a party aggrieved" may file a notice of appeal — language that does not distinguish between complainant and respondent. When the law speaks in clear and categorical language, there is no need for interpretation; words and phrases should be given their plain, ordinary meaning.

• Rule 43 Coverage: The Court agreed with petitioner that the PRC's absence from the enumeration in Section 1, Rule 43 does not imply its exclusion from coverage. The Rule expressly provides that it applies to appeals from awards, judgments, final orders, or resolutions "of any quasi-judicial agency in the exercise of its quasi-judicial functions." The phrase "among these agencies" confirms that the enumeration is not exclusive. The Court cited Yang vs. Court of Appeals, which held that B.P. Blg. 129, Section 29, conferred upon the Court of Appeals exclusive appellate jurisdiction over appeals from quasi-judicial agencies, including the PRC. The enactment of B.P. Blg. 129, the precursor of the present Rules of Civil Procedure, lodged with the Court of Appeals jurisdiction over appeals of decisions made by the PRC.

• Expert Testimony Requirement: Medical malpractice consists in the failure of a physician to apply that degree of care and skill ordinarily employed by the profession generally under similar conditions and circumstances. The four elements of medical negligence are duty, breach, injury, and proximate causation. The determination of the reasonable level of care and breach thereof requires expert testimony, and because the causes of injuries in malpractice actions are determinable only in light of scientific knowledge, expert testimony is usually necessary to support the conclusion as to causation. In this case, respondents did not present any expert testimony. Petitioner, however, presented Dr. Augusto M. Manalo, who specializes in gynecology and obstetrics, has authored various publications on the subject, and is a professor at the University of the Philippines. Dr. Manalo diagnosed Editha's case as "Ectopic Pregnancy Interstitial (also referred to as Cornual), Ruptured" and testified that the D&C procedure was not the proximate cause of the rupture because the instrument cannot reach the site of the pregnancy to push it outside the uterus, and if the D&C had caused the rupture, it would have occurred much earlier — right after or a few days after the procedure, not one and a half months later.

• Proximate Cause: Proximate cause is that which, in natural and continuous sequence, unbroken by any efficient intervening cause, produces injury, and without which the result would not have occurred. The Board of Medicine found that Editha was advised to return on August 4, 1994 for follow-up, as indicated in her Discharge Sheet, but failed to do so. Dr. Manalo testified that even assuming a misdiagnosis occurred, it would have been rectified had Editha returned for follow-up evaluation as instructed, since the continued growth of an ectopic pregnancy until its eventual rupture is a dynamic process, and much change in physical findings could be expected in one and a half months. Editha's omission in not returning for follow-up evaluation played a substantial part in bringing about her own injury. Had she returned, petitioner could have conducted proper medical tests and procedures to determine Editha's condition and applied treatment that could have prevented the rupture. The D&C procedure having been conducted in accordance with standard medical practice, Editha's omission was the proximate cause of her own injury — not merely contributory negligence. Where the immediate cause of an accident resulting in injury is the plaintiff's own act, she cannot recover damages.

• Due Process: It is a well-settled rule that when service of notice is an issue, the person alleging that the notice was served must prove the fact of service; the burden of proving notice rests upon the party asserting its existence. Respondents did not present any proof that petitioner was served a copy of the Memorandum on Appeal. Citing EDI-Staffbuilders International, Inc. vs. National Labor Relations Commission, where the NLRC's failure to order the private respondent to furnish the petitioner a copy of the Appeal Memorandum was held to deprive the petitioner of procedural due process, the Court found that respondents' failure to furnish petitioner a copy of the Memorandum on Appeal submitted to the PRC constituted a violation of due process, rendering the PRC proceedings null and void.

• Medical Malpractice / Medical Negligence — Medical malpractice is a particular form of negligence consisting in the failure of a physician or surgeon to apply to the practice of medicine that degree of care and skill ordinarily employed by the profession generally, under similar conditions and in like surrounding circumstances. The four elements are: duty, breach, injury, and proximate causation. A physician-patient relationship creates the duty to use at least the same level of care that any reasonably competent doctor would use to treat a condition under the same circumstances. Expert testimony is essential to establish both the reasonable level of care and breach thereof, and is usually necessary to support the conclusion as to causation, since causes of injuries in malpractice actions are determinable only in light of scientific knowledge.

• Proximate Cause — Proximate cause is 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 failure to act whenever it appears from the evidence that the act or omission played a substantial part in bringing about or actually causing the injury or damage, and that the injury was either a direct result or a reasonably probable consequence of the act or omission.

• Contributory Negligence vs. Proximate Cause — Contributory negligence is the act or omission amounting to want of ordinary care on the part of the person injured, which, concurring with the defendant's negligence, is the proximate cause of the injury. Where the immediate cause of an accident resulting in injury is the plaintiff's own act, which contributed to the principal occurrence as one of its determining factors, the plaintiff cannot recover damages. In this case, the Court held that Editha's failure to return for follow-up check-up was not merely contributory negligence but the proximate cause of her own injury.

• Right to Appeal as Statutory Privilege — The right to appeal is not a natural right or a part of due process, but a mere statutory privilege that may be exercised only in the manner prescribed by law.

• Rule 43 Non-Exclusive Enumeration — The enumeration of quasi-judicial agencies in Section 1, Rule 43 of the Rules of Court is non-exclusive, as indicated by the phrase "among these agencies." The absence of a quasi-judicial body from the enumeration does not imply its exclusion from the Rule's coverage, since the Rule expressly applies to appeals from "any quasi-judicial agency in the exercise of its quasi-judicial functions."

• Double Jeopardy in Administrative Cases — Double jeopardy does not apply to administrative proceedings. It attaches only upon a valid indictment, before a competent court, after arraignment, when a valid plea has been entered, and when the defendant was acquitted or convicted, or the case was dismissed or otherwise terminated without the express consent of the accused.

• Burden of Proving Service of Notice — When service of notice is an issue, the person alleging that the notice was served must prove the fact of service. The burden of proving notice rests upon the party asserting its existence.

• Physician Not Guarantor of Care — Doctors are protected by a special rule of law: they are not guarantors of care and are not insurers against mishaps or unusual consequences, especially if the patient herself did not exercise the proper diligence required to avoid the injury.

• "Clearly, from the testimony of the expert witness and the reasons given by him, it is evident that the D&C procedure was not the proximate cause of the rupture of Editha's uterus." — This passage states the Court's finding on proximate causation, grounded in expert testimony that the curettage instrument could not reach the site of an interstitial ectopic pregnancy and that rupture caused by D&C would have occurred much earlier.

• "The D&C procedure having been conducted in accordance with the standard medical practice, it is clear that Editha's omission was the proximate cause of her own injury and not merely a contributory negligence on her part." — This formulation distinguishes the patient's own omission as the sole proximate cause rather than mere contributory negligence, precluding recovery of damages under Article 2179 of the Civil Code.

• "Indeed, the PRC is not expressly mentioned as one of the agencies which are expressly enumerated under Section 1, Rule 43 of the Rules of Court. However, its absence from the enumeration does not, by this fact alone, imply its exclusion from the coverage of said Rule." — This passage establishes the non-exclusive character of the Rule 43 enumeration, confirming PRC coverage through the phrase "among these agencies."

• "The failure of the respondents to furnish the petitioner a copy of the Memorandum of Appeal submitted to the PRC constitutes a violation of due process. Thus, the proceedings before the PRC were null and void." — This statement invalidates the PRC appellate proceedings for lack of procedural due process, applying the burden-of-proof rule on service of notice.

• Yang vs. Court of Appeals, G.R. No. 48113, June 6, 1990, 186 SCRA 287 — Controlling precedent establishing that B.P. Blg. 129, Section 29, conferred upon the Court of Appeals exclusive appellate jurisdiction over appeals from decisions of the PRC, confirming that PRC appeals are cognizable by the CA.

• Tecson vs. Sandiganbayan, 376 Phil. 191 (1999) — Cited for the elements of double jeopardy, which the Court held are inapplicable to administrative proceedings.

• De Vera vs. Layague, 395 Phil. 253 (2000) — Followed for the proposition that double jeopardy does not lie in administrative cases.

• Reyes vs. Sisters of Mercy Hospital, 396 Phil. 87 (2000) — Cited for the definition of medical malpractice and the four elements of medical negligence (duty, breach, injury, proximate causation), and for the requirement of expert testimony as to the reasonable level of care and breach thereof.

• Garcia-Rueda vs. Pascasio, 344 Phil. 323 (1997) — Cited for the definition of actionable malpractice as the breach of professional duties of skill and care whereby the patient is injured.

• Cruz vs. Court of Appeals, 346 Phil. 872 (1997) — Cited for the proposition that expert testimony is usually necessary to support the conclusion as to causation in malpractice actions.

• Ramos vs. Court of Appeals, 378 Phil. 1198 (1999) — Cited for the definition of expert witness qualifications and the definition of proximate cause.

• EDI-Staffbuilders International, Inc. vs. National Labor Relations Commission, G.R. No. 145587, October 26, 2007, 537 SCRA 409 — Applied by analogy for the principle that failure to furnish the adverse party a copy of an appeal memorandum violates procedural due process and renders the proceedings null and void.

• Ma-ao Sugar Central Co., Inc. vs. Court of Appeals, G.R. No. 83491, August 27, 1990, 189 SCRA 88 — Cited for the definition of contributory negligence.

• Orosa vs. Roa, G.R. No. 140423, July 14, 2006, 495 SCRA 22 — Cited for the principle that the phrase "among these agencies" in Rule 43 confirms the enumeration is non-exclusive.

• Section 1, Rule 43, Rules of Court — Governs appeals from judgments or final orders of quasi-judicial agencies to the Court of Appeals. The Court held that the enumeration of agencies is non-exclusive, as indicated by the phrase "among these agencies," and that the PRC falls within its coverage.

• Section 29, Batas Pambansa Blg. 129 (Judiciary Reorganization Act of 1980) — Conferred upon the Court of Appeals exclusive appellate jurisdiction over all final judgments, decisions, resolutions, orders, or awards of quasi-judicial agencies, instrumentalities, boards, or commissions. The Court held that this provision lodged with the CA jurisdiction over appeals from the PRC.

• Section 26, Republic Act No. 2382 (The Medical Act of 1959) — Provides that the decision of the Board of Medical Examiners shall become final thirty days after promulgation unless the respondent appeals to the Commissioner of Civil Service (now PRC) and later to the Office of the President. The CA relied on this provision to hold that the proper remedy was appeal to the Office of the President; the Supreme Court implicitly rejected this interpretation by ruling that Rule 43 covers PRC decisions.

• Article IV, Section 35, Rules and Regulations Governing the Regulation and Practice of Professionals (as amended by Res. 174, Series of 1990) — Originally provided that the respondent may appeal the decision of the Board to the Commission, while the complainant may appeal only "when allowed by law." As amended, it provides that "the complainant/respondent may appeal." The Court held that the amendment settled any doubt and rendered the right to appeal available to both complainants and respondents.

• Article 2176, Civil Code — Provides that whoever by act or omission causes damage to another, there being fault or negligence, is obliged to pay for the damage done. The Court noted that medical malpractice is often brought as a civil action for damages under this article.

• Article 2179, Civil Code — Provides that when the plaintiff's own negligence was the immediate and proximate cause of his injury, he cannot recover damages; but if his negligence was only contributory, the plaintiff may recover damages subject to mitigation. The Court applied this provision to hold that Editha's own omission was the proximate cause of her injury, precluding recovery.

• PRC Resolution No. 06-342(A), New Rules of Procedure in Administrative Investigations — Provides that "a party aggrieved" by the decision, order, or resolution of the Board may file a notice of appeal to the Commission. The Court held that this language does not distinguish between complainant and respondent, confirming that either party may appeal.

Consuelo Ynares-Santiago (Associate Justice, Chairperson), Minita V. Chico-Nazario (Associate Justice), Antonio Eduardo B. Nachura (Associate Justice), and Ruben T. Reyes (Associate Justice) concurred in the decision. No separate concurring opinions were noted.