Cruz vs. Agas, Jr.

A finding of lack of probable cause by the Department of Justice in a preliminary investigation will not be disturbed by courts in the absence of grave abuse of discretion amounting to an evasion of positive duty or arbitrary and despotic exercise of power. In medical negligence cases, probable cause requires evidence that the physician either failed to do something a reasonably prudent doctor would have done, or did something a reasonably prudent doctor would not have done, and that such failure or action caused injury to the patient.

Dr. Jaime T. Cruz engaged the services of St. Luke's Medical Center for a medical check-up in May 2003. On May 29, 2003, he underwent scheduled gastroscopy and colonoscopy procedures performed by Dr. Felicisimo V. Agas, Jr. Following the procedure, Dr. Cruz experienced dizziness, breathing difficulty, and abdominal pain, subsequently collapsing in the comfort room. He was diagnosed with internal hemorrhage due to a partial tear of the colonic wall, requiring emergency exploratory laparotomy during which a portion of his sigmoid colon was removed. Dr. Cruz thereafter filed a criminal complaint alleging that Dr. Agas performed the colonoscopy with reckless imprudence, causing serious physical injuries.

• The Medical Procedure: On May 28, 2003, Dr. Cruz was admitted to St. Luke's Medical Center (SLMC) for a medical check-up. The following day, he underwent scheduled gastroscopy and colonoscopy procedures at the Gastro-Enterology Department performed by Dr. Agas. Dr. Cruz alleged that prior to the procedure, the assigned specialist was nowhere to be found, and he merely gave the colonoscopy results to the attending female anesthesiologist.
• Post-Procedure Complications: Upon regaining consciousness after sedation, Dr. Cruz felt dizzy, experienced cold clammy perspiration and breathing difficulty, and could not stand or sit upright due to exhaustion and abdominal pain. While attempting to urinate in the comfort room, he collapsed. His cardiologist, Dra. Agnes Del Rosario, observed his critical condition and referred him to the surgical department, which suspected abdominal hemorrhage and advised emergency surgery.
• Surgical Findings: An exploratory laparotomy performed on May 30, 2003, revealed internal bleeding caused by a partial tear of the colonic wall. The surgeons removed a 6-8 inch portion of the left side of his colon. During his recovery in the ICU, Dr. Cruz experienced tremendous pain, fever, and required multiple intravenous tubes and a nasogastric tube. He was discharged on June 7, 2003, but claimed continued weakness, digestive difficulties, and fresh blood stools.
• Defense Evidence: Dr. Agas maintained that he conferred with Dr. Cruz and reviewed his medical history before the procedure. He submitted certifications and sworn statements from the Assistant Medical Director for Professional Services, the Director of the Institute of Digestive Diseases, the anesthesiologist, and the hospital nurse attesting that the procedures were successful, vital signs remained normal throughout, and the complications were immediately recognized and managed. Dr. Agas explained that the tear in the serosa resulted from marked adhesions and tortuosity of the sigmoid colon—abnormal conditions not detectable prior to the procedure through clinical findings, laboratory tests, or diagnostic imaging (x-ray, ultrasound, or CT scan), as these adhesions are located in the outer wall of the colon while the colonoscope only views the inner lining.
• Proceedings Below: The Office of the City Prosecutor dismissed the complaint on February 16, 2004, finding no probable cause. The DOJ affirmed this dismissal on March 2, 2007, and denied reconsideration on September 23, 2009. The Court of Appeals affirmed the DOJ resolutions on May 22, 2012, noting that Dr. Cruz failed to specify the procedures Dr. Agas failed to perform or the medical norms he violated.

• Executive Determination of Probable Cause: Petitioner contended that the Court of Appeals erred in affirming the Department of Justice resolutions dismissing the complaint, arguing that the DOJ gravely abused its discretion in finding no probable cause to file an information for serious physical injuries through reckless imprudence and medical malpractice.
• Medical Negligence: Petitioner maintained that Dr. Agas committed specific negligent acts during the colonoscopy procedure that caused the tear in his sigmoid colon, resulting in serious physical injuries requiring surgical removal of a portion of his colon.
• Due Process: Petitioner implied that the dismissal of his complaint constituted a denial of due process, as indicated in the issue he formulated regarding whether there was denial of due process in the proceedings.

• Lack of Probable Cause: Respondent countered that the DOJ correctly determined the absence of probable cause, as the executive determination of probable cause in preliminary investigations is entitled to great respect and should not be disturbed absent grave abuse of discretion.
• Absence of Negligence: Respondent argued that he provided adequate and reasonable standard of care, followed all precautionary measures, and did not deviate from standard medical norms. He maintained that the complication resulted from the abnormal condition and configuration of Dr. Cruz's digestive system—specifically marked adhesions in the sigmoid colon—which were beyond his control and undetectable prior to the procedure through any clinical or diagnostic means.
• Inapplicability of Res Ipsa Loquitur: Respondent contended that the doctrine of res ipsa loquitur did not apply because the injury was not immediately apparent to a layman and required expert medical opinion to establish the correlation between the colonoscopy and the serosal tear.

• Executive Determination of Probable Cause: Whether the Court of Appeals correctly affirmed the Department of Justice finding that no probable cause exists for filing an information against respondent.
• Medical Negligence: Whether respondent was negligent in performing the colonoscopy procedure.
• Due Process: Whether petitioner was denied due process in the preliminary investigation proceedings.

• Executive Determination of Probable Cause: The Court of Appeals correctly affirmed the Department of Justice resolutions. Under the doctrine of separation of powers, courts will not interfere with the executive determination of probable cause for the purpose of filing an information absent grave abuse of discretion—that is, abuse so patent and gross as to amount to an evasion of positive duty or a virtual refusal to perform a duty enjoined by law, or exercise of power in an arbitrary and despotic manner by reason of passion or hostility. No such grave abuse was established in this case.
• Medical Negligence: Medical negligence was not established. The elements of a medical negligence claim are: (1) duty; (2) breach; (3) injury; and (4) proximate causation. A patient must prove that a health care provider either failed to do something which a reasonably prudent provider would have done, or did something that a reasonably prudent provider would not have done, and that such failure or action caused injury. Dr. Cruz failed to identify specific negligent or reckless acts or omissions by Dr. Agas, or to demonstrate "inexcusable lack of precaution" on the latter's part. While the injury (internal hemorrhage due to serosal tear) was undisputed, petitioner failed to establish that it was caused by respondent's negligent conduct during the colonoscopy.
• Res Ipsa Loquitur: The doctrine of res ipsa loquitur was inapplicable. The requisites for its application are: (1) 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) absence of explanation by the defendant. The most instrumental requisite is control and management of the thing causing the injury. Here, the purported negligence was not immediately apparent to a layman. Dr. Agas adequately established that the injury resulted from marked adhesions in the sigmoid colon—an abnormal condition not detectable prior to the procedure through clinical findings, laboratory tests, or diagnostic imaging, and located in the outermost layer of the colon beyond the reach of the colonoscope. The correlation between the injury and the procedure required expert opinion, which Dr. Cruz failed to provide.

• Non-interference with Executive Determination of Probable Cause — Courts have no right to directly decide matters over which full discretionary authority has been delegated to the Executive Branch, or to substitute their judgment for that of the Executive. The settled policy is that courts will not interfere with the executive determination of probable cause for the purpose of filing an information absent grave abuse of discretion. Grave abuse of discretion must be so patent and gross as to amount to an evasion of a positive duty or a virtual refusal to perform a duty enjoined by law, or to act at all in contemplation of law, such as where power is exercised in an arbitrary and despotic manner by reason of passion or hostility.
• Elements of Medical Negligence — To successfully pursue a medical negligence case, a patient must prove: (1) duty; (2) breach; (3) injury; and (4) proximate causation. Specifically, the patient must show that the health care provider either failed to do something which a reasonably prudent health care provider would have done, or did something that a reasonably prudent provider would not have done, and that such failure or action caused injury to the patient.
• Res Ipsa Loquitur — Literally meaning "the thing speaks for itself," this doctrine permits an inference or raises a presumption of negligence where: (1) an injury occurs; (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) there is absence of explanation by the defendant. The most instrumental requisite is the control and management of the thing which caused the injury. The doctrine does not apply where the negligence is not immediately apparent to a layman or where the defendant provides an adequate explanation for the occurrence.

• "The settled policy is that the courts will not interfere with the executive determination of probable cause for the purpose of filing an Information, in the absence of grave abuse of discretion."
• "That abuse of discretion must be so patent and gross as to amount to an evasion of a positive duty or a virtual refusal to perform a duty enjoined by law or to act at all in contemplation of law, such as where the power is exercised in an arbitrary and despotic manner by reason of passion or hostility."
• "A medical negligence case can prosper if the patient can present solid proof that the doctor... either failed to do something which a reasonably prudent doctor would have done, or that he did something that a reasonably prudent doctor would not have done, and such failure or action caused injury to the patient."
• "Simply put, the elements are duty, breach, injury and proximate causation."
• "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."

• Professional Services, Inc. v. Natividad and Enrique Agana, 542 Phil. 464 (2007) — Cited as controlling precedent for the definition of medical negligence, the elements required to establish it (duty, breach, injury, proximate causation), and the requisites for the application of the doctrine of res ipsa loquitur in medical malpractice cases.

• Rule 45, Rules of Court — Governs petitions for review on certiorari to the Supreme Court.
• Section 13, Article VIII, 1987 Constitution — Basis for the certification by the Chief Justice that the conclusions in the decision were reached in consultation before the case was assigned to the writer of the opinion.

Antonio T. Carpio (Chairperson), Arturo D. Brion, Mariano C. Del Castillo, Francis H. Jardeleza (Designated Acting Member)