Jarcia, Jr. vs. People

A physician's failure to diagnose an injury may give rise to civil liability for negligence under a preponderance of evidence standard even where criminal liability is not established beyond reasonable doubt, provided the negligence is shown to have contributed to the patient's injury; and the doctrine of res ipsa loquitur cannot be applied where the instrumentality or circumstances causing the injury were not under the exclusive control of the defendant.

Roy Alfonso Santiago, Jr. ("Roy Jr."), a child of tender age, was struck by a taxicab and brought to the emergency room of Manila Doctors Hospital for treatment. Dr. Emmanuel Jarcia, Jr. and Dr. Marilou Bastan were junior residents in general surgery at the hospital who attended to the victim at the ER. Belinda Santiago, Roy Jr.'s mother, subsequently lodged a complaint with the National Bureau of Investigation alleging that the doctors' neglect of professional duty caused her son to suffer serious physical injuries. The NBI endorsed the matter to the Office of the City Prosecutor of Manila, which found probable cause and filed a criminal case for reckless imprudence resulting to serious physical injuries against Dr. Jarcia, Dr. Bastan, and Dr. Pamittan before the RTC.

Roy Alfonso Santiago, Jr., a child of tender age, was hit by a taxicab and rushed to the emergency room of Manila Doctors Hospital for immediate medical treatment. An X-ray of the victim's ankle was ordered, and the result, as read by Dr. Emmanuel Jarcia, Jr., showed no fracture. Dr. Marilou Bastan then entered the ER and, after conducting her own examination, informed Roy Jr.'s mother, Belinda Santiago, that since it was only the ankle that was hit, there was no need to examine the upper leg. Mrs. Santiago had asked whether the entire leg should be X-rayed, as her son was complaining of pain from the ankle up to the middle part of the right leg, but Dr. Bastan refused, explaining that only the ankle region had been struck. The doctors cleaned the wounds and assured the mother that everything was fine and that they could go home.

Eleven days later, Roy Jr. developed fever, swelling of the right leg, and misalignment of the right foot. Mrs. Santiago brought him back to the hospital, where a new X-ray revealed a right mid-tibial fracture and a linear hairline fracture in the shaft of the bone — a spiral fracture approximately six to eight centimeters long. The mother subsequently filed a complaint with the NBI, which investigated and endorsed the matter to the Office of the City Prosecutor. A criminal case for reckless imprudence resulting to serious physical injuries was filed against Dr. Jarcia, Dr. Bastan, and Dr. Pamittan before the RTC, docketed as Criminal Case No. 01-196646.

During trial, the prosecution presented Mrs. Santiago, who testified about the events at the ER and recounted that the doctors had admitted their mistakes during a meeting with a hospital representative. The prosecution also presented Dr. Cirilo Tacata, a specialist in pediatric orthopedics and chairman of the Department of Orthopedics at UP-PGH, who examined Roy Jr. and testified that the standard practice for a suspected fracture would be to X-ray the entire extremity. Dr. Tacata acknowledged, however, that Dr. Jarcia and Dr. Bastan were general surgery residents — not orthopedic specialists — and that whether an X-ray of the entire leg would have been warranted depended on the clinical examination. He could not definitively state that the failure to X-ray the upper leg aggravated the child's condition. The RTC found the petitioners guilty of simple imprudence resulting to serious physical injuries, a conviction affirmed in toto by the Court of Appeals, which additionally applied the doctrine of res ipsa loquitur.

• Proximate Cause: Petitioner argued that the actual, direct, immediate, and proximate cause of the patient's physical injury was the vehicular accident in which his right leg was hit by a taxi, not the failure to subject the patient's whole leg to an X-ray examination.
• Disregard of Expert Testimony: Petitioner maintained that the Court of Appeals unjustifiably disregarded the opinion of the prosecution's expert witness, Dr. Cirilo Tacata, who testified that the petitioners were not guilty of negligence or imprudence.
• Unsupported Conclusion on Prolonged Suffering: Petitioner argued that the CA's conclusion that the failure to X-ray the whole leg prolonged the patient's pain and suffering was unsupported by, and even contrary to, the evidence on record.
• Contributory Negligence of the Mother: Petitioner contended that assuming prolonged pain and suffering occurred, these were due to the unjustified failure of the patient's mother — a nurse herself — to immediately bring the patient back to the hospital after he complained of severe pain upon reaching home.
• Absence of Physician-Patient Relationship: Petitioner asserted that no physician-patient relationship existed between them and the patient, as they were not his attending physicians but were merely requested by the ER nurse to see the patient while passing by the ER for lunch.

• Applicability of Res Ipsa Loquitur: Whether the doctrine of res ipsa loquitur is applicable to the facts of this case.
• Criminal Negligence: Whether the petitioners are liable for criminal negligence, specifically simple imprudence resulting to serious physical injuries.
• Physician-Patient Relationship: Whether a physician-patient relationship existed between the petitioners and the patient.
• Civil Liability and Damages: Whether the petitioners are civilly liable for the resulting damages to the patient, and if so, what amounts are proper.

• Applicability of Res Ipsa Loquitur: No. The doctrine does not apply because the circumstances that caused the patient's injury and the series of tests to determine its extent were not under the exclusive control of the petitioners, who were mere residents attending to the victim at the ER.
• Criminal Negligence: No. The elements of reckless imprudence or simple negligence were not proved beyond reasonable doubt, as the expert testimony of Dr. Tacata did not clearly establish that the petitioners' failure to diagnose the fracture aggravated the patient's condition or prolonged his suffering.
• Physician-Patient Relationship: Yes. A physician-patient relationship was established when the petitioners examined the victim and assured the mother that everything was fine, regardless of whether they were merely passing by the ER; moreover, the issue was raised for the first time on appeal and cannot be entertained.
• Civil Liability and Damages: Yes. The petitioners are civilly liable under a preponderance of evidence standard for failing to perform an extensive medical examination and for not referring the patient to a specialist; actual damages of ₱3,850.00, moral damages of ₱100,000.00, and exemplary damages of ₱50,000.00 are awarded.

• Applicability of Res Ipsa Loquitur: The doctrine of res ipsa loquitur requires, among other things, that the instrumentality or agency which caused the injury be under the exclusive control of the person in charge. In this case, the circumstances that caused Roy Jr.'s injury and the series of tests that were supposed to be undergone to determine the extent of the injury were not under the exclusive control of Drs. Jarcia and Bastan. They were mere residents of the hospital who attended to the victim at the emergency room. The element of exclusive control being absent, the doctrine cannot be invoked. The Court emphasized that res ipsa loquitur is not a rule of substantive law but merely a mode of proof or procedural convenience, and it cannot dispense with the requirement of proof of culpable negligence. Furthermore, whether the petitioners exercised the requisite degree of skill and care is generally a matter of expert opinion, not something to be resolved through lay assumptions.

• Criminal Negligence: While the totality of the evidence pointed to negligence on the part of the petitioners, the Court was not satisfied with moral certainty that they were guilty of reckless imprudence or simple negligence. The testimony of Dr. Tacata, although indicating that certain medical procedures could have been performed, was not clear as to whether the injuries suffered by Roy Jr. were indeed aggravated by the petitioners' judgment call and their diagnosis. There was no precise evidence or scientific explanation showing that the delay in applying a cast due to the failure to immediately diagnose the specific injury prolonged the child's pain, aggravated his condition, or caused further complications. Any person may logically opine that earlier detection could have prevented prolonged suffering, but such opinion — however logical — is insufficient to hold one criminally liable. The constitutional presumption of innocence requires proof beyond reasonable doubt, which was not met.

• Physician-Patient Relationship: The issue of absence of physician-patient relationship was raised for the first time on appeal before the Supreme Court, having never been raised before the RTC or the CA. It is settled that issues raised for the first time on appeal cannot be considered, as a party is not permitted to change his theory on appeal; doing so would be unfair to the opposing party and offensive to the rules of fair play, justice, and due process. Assuming arguendo that the issue could still be raised, the Court found that a physician-patient relationship was established: the patient and his mother went to the ER for immediate medical attention, the petitioners examined the victim, and they assured the mother that everything was fine and they could go home. By examining the patient and providing assurance, the petitioners undertook the duties of attending physicians.

• Civil Liability and Damages: While criminal conviction requires proof beyond reasonable doubt, only a preponderance of evidence is required to establish civil liability. The petitioners were remiss in their duties as members of the medical profession by failing to perform an extensive medical examination to determine the extent of Roy Jr.'s injuries. If they lacked the capacity to make a thorough evaluation, they should have referred the patient to another doctor with sufficient training and experience. Their negligence was contributory to the resulting damages, even though the taxi driver was the proximate cause of the original injury. The amount of ₱3,850.00 in actual damages was adequately supported by receipts. Moral damages of ₱100,000.00 were proper to compensate the physical suffering, mental anguish, and serious anxiety unjustly inflicted on the patient. Exemplary damages of ₱50,000.00 were warranted under Article 2229 of the Civil Code as a correction for the public good. Interest at 6% per annum was imposed from the date of filing of the Information, and 12% per annum from finality of judgment until fully paid.

• Res Ipsa Loquitur — A rule of evidence whereby negligence of the alleged wrongdoer may be inferred from the mere fact that the accident happened, provided the character of the accident and the circumstances attending it lead reasonably to the belief that, in the absence of negligence, it would not have occurred, and that the thing which caused injury is shown to have been under the management and control of the alleged wrongdoer. The requisites are: (1) the accident was of a kind which does not ordinarily occur unless someone is negligent; (2) the instrumentality or agency which caused the injury was under the exclusive control of the person in charge; and (3) the injury suffered must not have been due to any voluntary action or contribution of the person injured. The doctrine is not a rule of substantive law but merely a mode of proof or procedural convenience; it does not dispense with the requirement of proof of culpable negligence. In this case, the doctrine was held inapplicable because the circumstances causing the injury were not under the exclusive control of the petitioners, who were mere hospital residents.

• Standard of Care in Medical Negligence — In accepting a case, a physician represents that he has the needed training and skill possessed by physicians and surgeons practicing in the same field, and that he will employ such training, care, and skill in the treatment of the patient. The physician has the obligation to use at least the same level of care that any other reasonably competent physician would use to treat the condition under similar circumstances. Whether a physician exercised the requisite degree of skill and care is generally a matter of expert opinion. In this case, the petitioners, as general surgery residents without orthopedic specialization, should have referred the patient to a specialist when they could not competently evaluate the injury.

• Distinction Between Criminal and Civil Liability for Negligence — Criminal negligence requires proof beyond reasonable doubt, while civil liability for negligence requires only a preponderance of evidence. A person may be acquitted of criminal negligence but still be held civilly liable where the evidence preponderates in favor of the plaintiff. In this case, the petitioners were acquitted of the crime but held civilly liable for actual, moral, and exemplary damages.

• Physician-Patient Relationship — A physician-patient relationship is generated when a patient engages the services of a physician, or when a physician examines and treats a patient who presents himself for medical attention. The relationship imposes on the physician a duty to exercise the degree of care, skill, and diligence which physicians in the same general neighborhood and in the same general line of practice ordinarily possess and exercise in like cases. In this case, the relationship was established when the petitioners examined the victim at the ER and assured the mother that everything was fine.

• Prohibition on Raising New Issues on Appeal — Issues and theories not brought to the attention of the trial court cannot be raised for the first time on appeal, as this would be unfair to the opposing party and offensive to the rules of fair play, justice, and due process. The petitioners' claim of absence of physician-patient relationship was raised for the first time before the Supreme Court and was thus barred.

• "The totality of the evidence on record clearly points to the negligence of the petitioners. At the risk of being repetitious, the Court, however, is not satisfied that Dr. Jarcia and Dr. Bastan are criminally negligent in this case." — This passage articulates the Court's critical distinction between civil negligence, which was established, and criminal negligence, which was not proved beyond reasonable doubt.

• "Any person may opine that had patient Roy Jr. been treated properly and given the extensive X-ray examination, the extent and severity of the injury, spiral fracture of the mid-tibial part or the bigger bone of the leg, could have been detected early on and the prolonged pain and suffering of Roy Jr. could have been prevented. But still, that opinion, even how logical it may seem would not, and could not, be enough basis to hold one criminally liable; thus, a reasonable doubt as to the petitioners' guilt." — This passage defines the boundary between logical inference and the quantum of proof required for criminal conviction, anchoring the acquittal on the presumption of innocence.

• "While a criminal conviction requires proof beyond reasonable doubt, only a preponderance of evidence is required to establish civil liability." — This formulation states the controlling principle that permitted the Court to acquit the petitioners criminally while simultaneously holding them civilly liable, a dual disposition central to the decision's dispositive.

• "In this case, the circumstances that caused patient Roy Jr.'s injury and the series of tests that were supposed to be undergone by him to determine the extent of the injury suffered were not under the exclusive control of Drs. Jarcia and Bastan." — This passage supplies the ratio decidendi for the inapplicability of res ipsa loquitur, focusing on the absence of the exclusive-control requisite.

• Lucas vs. Tuaño, G.R. No. 178763, April 21, 2009, 586 SCRA 173 — Followed. Cited for the proposition that a physician-patient relationship is generated when a patient engages the services of a physician, and that the physician has a duty to exercise the degree of care, skill, and diligence ordinarily possessed by physicians in the same line of practice.

• Reyes vs. Sisters of Mercy Hospital, 396 Phil. 87 (2000) — Followed. Cited for the three requisites for the application of the doctrine of res ipsa loquitur.

• Dr. Batiquin vs. Court of Appeals, 327 Phil. 965 (1996) — Followed. Cited for the principle that res ipsa loquitur is not a rule of substantive law but merely a mode of proof or procedural convenience, and that it does not dispense with the requirement of proof of culpable negligence.

• Leonila Garcia-Rueda vs. Pascasio — Followed. Cited by the Court of Appeals for the standard of care in medical negligence: a physician represents that he has the needed training and skill and will employ such care in treatment.

• Gaid vs. People, G.R. No. 171636, April 7, 2009, 584 SCRA 489 — Followed. Cited for the definitions of negligence, reckless imprudence, and the elements of simple negligence under the Revised Penal Code.

• Balitaosan vs. The Secretary of Education, 457 Phil. 300 (2003) — Followed. Cited for the rule that issues raised for the first time on appeal cannot be considered.

• Quezon City Govt. vs. Dacara, 499 Phil. 228 (2005) — Followed. Cited for the nature and purpose of moral damages as compensatory rather than punitive.

• Article 365, Revised Penal Code — Defines reckless imprudence and simple imprudence and prescribes the penalties therefor. The RTC applied this provision in convicting the petitioners of simple imprudence resulting to serious physical injuries; the Supreme Court found that the elements thereof were not proved beyond reasonable doubt.

• Article 2229, Civil Code — Authorizes the imposition of exemplary damages by way of example or correction for the public good. The Court applied this provision in awarding ₱50,000.00 in exemplary damages against the petitioners.

• Article II, Section 1, Code of Medical Ethics of the Medical Profession in the Philippines — Provides that a physician should attend to his patients faithfully and conscientiously and secure for them all possible benefits that may depend upon his professional skill and care. The Court invoked this provision to underscore the petitioners' failure to observe prudent medical procedure.

Antonio T. Carpio, Diosdado M. Peralta (Acting Chairperson), Roberto A. Abad, and Jose Portugal Perez concurred.