Reyno vs. Baltazar

The doctrine of res ipsa loquitur applies in medical negligence cases where the patient's injury or death is such that it would not ordinarily occur absent negligence, the instrumentality causing the harm was under the exclusive control of the defendant, and the patient did not contribute to the injury. When these elements are present, the plaintiff need not produce expert medical testimony to establish the standard of care, as the injury itself provides proof of negligence.

The respondents, George Baltazar and Joel Baltazar, are the husband and son of Teresita Laurena Baltazar, a diabetic patient who was referred to Dr. Jade P. Malvar for treatment of a wound on her left foot. Due to financial constraints, Dr. Malvar advised that Teresita be transferred from Callang's General Hospital to the government-run Echague District Hospital, where she was admitted for a scheduled debridement procedure. The case involves the liability of healthcare providers, specifically nurses, for the death of a patient under their care, and the application of the doctrine of res ipsa loquitur in medical negligence actions.

Teresita Laurena Baltazar, a diabetic patient, was referred to Dr. Jade P. Malvar for a wound on her left foot. Dr. Malvar advised debridement, a minor and superficial procedure to clean the wound. Due to financial constraints, Dr. Malvar suggested that Teresita transfer to the government-run Echague District Hospital, where she was admitted on June 9, 2009, between 8:00 p.m. and 9:00 p.m., in time for her scheduled surgery the following day.

As part of Teresita's treatment, Dr. Malvar consulted Dr. Cabucana De Guzman, a diabetes specialist, who instructed that Teresita be administered insulin at 6:00 a.m., 12:00 n.n., 6:00 p.m., and 12:00 m.n., with a Random Blood Sugar test required prior to each insulin injection. These instructions were left to the nurses on ward duty: Gigi Tomas, on duty from 12 m.n. to 8:00 a.m.; De Vera, on duty from 8:00 a.m. to 4:00 p.m.; and Reyno, on duty from 4:00 p.m. to 12:00 m.n.

On June 10, 2009, at 10:30 a.m., George and Joel visited Teresita, who seemed to be in high spirits. At 11:15 a.m., Tomas endorsed Teresita to De Vera, who administered insulin at 11:30 a.m. Dr. Malvar, along with anesthesiologist Dr. Baby Delfin L. Cabansag, then performed the debridement, which ended at 12:20 n.n. without complications. After the operation, Teresita was assigned to recover in the ward. When De Vera's shift ended at 4:00 p.m., she endorsed Teresita to the incoming nurse, Reyno.

At 5:00 p.m., Joel visited his mother. At 5:20 p.m., Reyno administered insulin to Teresita. After about an hour, Reyno removed the oxygen mask attached to Teresita, despite Joel's protestations, informing him that the hospital was short of oxygen masks and that another patient needed it. She sought permission from Dr. Cabansag, considering Teresita's stable condition. Moments later, Teresita's health deteriorated as Joel noticed she was having difficulty breathing. When Joel informed Reyno, she retorted defensively, saying "wala akong kinakatakutan ... kahit magsumbong ka sa mga taga hospital," but immediately returned the oxygen mask.

When Teresita's difficulty in breathing persisted and she began to salivate, Reyno called Dr. Malvar, who instructed her to administer a "fifty-fifty intravenous." When Teresita's blood pressure began to fluctuate, Reyno called Dr. Malvar a second time and sought the help of the resident physician on duty, Dr. Honorio I. Caramancion, who administered epinephrine as an emergency measure. Upon checking Teresita's heartbeat and pulse rate, Dr. Caramancion noticed she was unresponsive and declared her dead. Dr. Malvar arrived shortly thereafter and attempted to resuscitate her, but to no avail. Teresita was pronounced dead at 7:00 p.m.

George and Joel instituted an action for damages against the local government of Isabela, Dr. Ventura, Dr. Caramancion, and nurses Reyno and De Vera. The RTC dismissed the complaint, holding that the cause of death was not clearly established absent an autopsy, and that there was no negligence on the part of the hospital staff. The CA reversed as to Reyno and De Vera, applying the doctrine of res ipsa loquitur and holding them jointly and severally liable for damages. The CA found that Teresita was injected with insulin without an RBS test as required by the doctors' pre-operation orders, exposing her to the risk of hypoglycemia, which could cause death. The CA also noted that Teresita was not given any food since the day before her operation until her death, contrary to the doctors' instructions.

• Procedural Due Process: Petitioners argued that the CA erred in finding that the respondents' motion for reconsideration, which lacked a notice of hearing, substantially complied with the requirements of procedural due process. They insisted that the RTC Decision already became final and executory, as the motion for reconsideration did not suspend the running of the prescriptive period to file an appeal.

• Lack of Evidence of Medical Negligence: Petitioners argued that respondents failed to establish by evidence the elements of a medical negligence case on the ground that Teresita was not autopsied so as to ascertain the exact cause of her death.

• Inapplicability of Res Ipsa Loquitur: Petitioners averred that the doctrine of res ipsa loquitur bears no applicability in this case. They argued that the order to conduct an RBS test was an order prior to the operation and was never ordered by Dr. Malvar after Teresita's operation. They further contended that it was never conclusively found that the failure to carry out such an order was the cause of Teresita's death, as her death may be attributed to a lot of causes which were never established by preponderance of evidence.

• Rehash of Prior Arguments: Respondents asserted that the grounds raised by petitioners were a mere rehash of those already passed upon by the CA.

• Applicability of Res Ipsa Loquitur: Respondents asserted that given the negligence of petitioners as found by the CA, the principle of res ipsa loquitur is applicable in this case.

• Question of Fact: Respondents argued that the question of negligence is a question of fact, which may no longer be questioned in a petition for review on certiorari.

• Procedural Due Process: Whether the CA erred in its finding that the motion for reconsideration of respondents, which lacked a notice of hearing, substantially complied with the requirements of procedural due process.

• Res Ipsa Loquitur: Whether the CA erred in its application of the doctrine of res ipsa loquitur in finding that petitioners' negligence caused the death of Teresita.

• Procedural Due Process: No. The CA did not err in finding that the motion for reconsideration substantially complied with the requirements of procedural due process, even absent a notice of hearing. The purpose of the notice requirement — to apprise the adverse party of the motion and afford an opportunity to be heard — was served, as petitioners were able to file comments/oppositions to the motion.

• Res Ipsa Loquitur: No. The CA correctly applied the doctrine of res ipsa loquitur. All three elements for its application were present: the death of a patient following a routine debridement would not ordinarily occur absent negligence; Teresita was under the exclusive care and control of petitioners as ward nurses; and Teresita could not have contributed to her own death.

• Procedural Due Process: The Court sustained the CA ruling, citing Jehan Shipping Corporation vs. National Food Authority, which held that the omission of a notice of hearing does not prove fatal to motions if the adverse party actually had the opportunity to be heard. The test is the presence of the opportunity to be heard, as well as time to study the motion and meaningfully oppose or controvert the grounds upon which it is based. In this case, petitioners were given the opportunity to file a comment/opposition on the motion for reconsideration and another comment/opposition on the notice of appeal. The Court further noted that pursuant to the Amended Rules on Civil Procedure, effective May 1, 2020, there is no longer a requirement for motions to contain a notice of hearing; it is now the court's discretion to call a hearing on the motion.

• Res Ipsa Loquitur: The Court applied the doctrine of res ipsa loquitur, a Latin maxim meaning "the thing or the transaction speaks for itself." The doctrine is a matter of evidence, not a rule of substantive law, and permits the plaintiff to create an inference or presumption of negligence, placing on the defendant the burden of proving there was no negligence. The elements are: (1) the accident was of such character as to warrant an inference that it would not have happened except for the defendant's negligence; (2) the accident must have been caused by an agency or instrumentality within the exclusive management or control of the person charged with the negligence; and (3) the accident must not have been due to any voluntary action or contribution on the part of the person injured.

The Court found all elements present. Teresita submitted herself for a routine debridement, which was successful and without complications. The death of a patient following such a minor procedure would not occur under normal circumstances unless negligence had set in. Teresita was under the exclusive care and control of petitioners as ward nurses, who were charged with carrying out doctor's orders, administering prescribed medicines and treatments, and answering to patients' needs. Teresita could not have contributed to her death, as she remained dependent on petitioners for post-operation treatments.

The Court relied on Teresita's Certificate of Death, which indicated the causes of death as "Metabolic Encephalopathy versus Myocardial Infarction," with antecedent cause "Hypoglycemia versus Myocardial Infarction" and underlying cause "Probably Hypoglycemia versus Myocardial Infarction." Citing Philam Life Insurance Company vs. Court of Appeals, the Court held that death certificates are prima facie evidence of facts therein stated, and a duly-registered death certificate is considered a public document whose entries are presumed correct.

The Court credited Dr. Malvar's testimony that petitioners were remiss in their duties for injecting insulin without the necessary RBS test, causing Teresita to develop hypoglycemia, a life-threatening condition for diabetes patients. The Court noted that the nurses' instructions required an RBS test prior to each insulin injection, and documentary evidence proved that Teresita was injected with insulin twice — at 11:30 a.m. by De Vera and at 5:20 p.m. by Reyno — without the required RBS test. The Court rejected petitioners' denial that an RBS test was conducted, noting that De Vera was found guilty of negligence in an investigation conducted by Dr. Ventura, and that there was no record confirming the conduct of an RBS test prior to the insulin injections. The Court observed that all other orders, such as monitoring vital signs and administering oral and IV medications, were recorded, except the conduct of an RBS test.

The Court held that expert medical testimony was not required, citing Ramos vs. Court of Appeals, because when the doctrine of res ipsa loquitur is availed, the need for expert medical testimony is dispensed with because the injury itself provides the proof of negligence. The Court emphasized that intent is immaterial in negligence cases because where negligence exists and is proven, the same automatically gives the injured a right to reparation for the damage caused.

• Res Ipsa Loquitur — A Latin maxim meaning "the thing or the transaction speaks for itself." The doctrine is a mode of proof and a matter of evidence, not a rule of substantive law; it does not create or constitute an independent or separate ground of liability. It permits the plaintiff to present, along with proof of the accident, enough of the attending circumstances to invoke the doctrine, create an inference or presumption of negligence, and thereby place on the defendant the burden of proving that there was no negligence on his part. The elements are: (1) the accident was of such character as to warrant an inference that it would not have happened except for the defendant's negligence; (2) the accident must have been caused by an agency or instrumentality within the exclusive management or control of the person charged with the negligence complained of; and (3) the accident must not have been due to any voluntary action or contribution on the part of the person injured. In medical negligence cases, when the doctrine is appropriate, all that is required of the patient or the complaining party is to 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.

• Substantial Compliance with Notice of Hearing Requirement — The notice of hearing requirement for motions, embodied in Section 5, Rule 15 of the 1997 Rules on Civil Procedure, is mandatory in nature. However, the omission of a notice of hearing does not prove fatal to a motion if the adverse party actually had the opportunity to be heard. The test is the presence of the opportunity to be heard, as well as time to study the motion and meaningfully oppose or controvert the grounds upon which it is based. A liberal construction of procedural rules is proper where the lapse in the literal observance of a rule of procedure has not prejudiced the adverse party and has not deprived the court of its authority.

• Prima Facie Evidentiary Value of Death Certificates — A duly-registered death certificate is considered a public document and the entries found therein are presumed correct, unless the party who contests its accuracy can produce positive evidence establishing otherwise. Death certificates are prima facie evidence of facts therein stated.

• "There must be reasonable evidence of negligence. But where the thing is shown to be under the management of the defendant or his servants, and the accident is such as in the ordinary course of things does not happen if those who have the management use proper care, it affords reasonable evidence, 'in the absence of explanation by the defendants, that the accident arose from want of care." — This is the canonical formulation of the doctrine of res ipsa loquitur from Scott v. London & St. Katherine Docks Co., quoted by the Court as the foundational statement of the doctrine.

• "The test is the presence of the opportunity to be heard, as well as to have time to study the motion and meaningfully oppose or controvert the grounds upon which it is based." — This passage from Jehan Shipping Corporation v. National Food Authority articulates the standard for determining whether there has been substantial compliance with the notice of hearing requirement in procedural due process.

• "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." — This passage from Ramos v. Court of Appeals explains why expert testimony is not required when res ipsa loquitur applies, as the injury itself provides proof of negligence.

• "I have ordered in the chart that before we give insulin, blood sugar should be requested. Now, the reason for that is that, if the insulin as mentioned by the previous attorney, if the insulin is high, it means it is justifiable to give the insulin. However, if it is normal or low, the insulin should not be given. The reason is that you are going to deplete the patient from glucose which is supposed to be the energy of the entire body from the brain down to the vital organs. Now, if you give insulin without testing the blood sugar, you are exposing the patient of a very risk of Hypoglycemia." — Dr. Malvar's testimony explaining the medical necessity of conducting an RBS test prior to insulin administration, which the Court credited in finding the nurses negligent.

• Jehan Shipping Corporation vs. National Food Authority, 514 Phil. 166 (2005) — Controlling precedent on the issue of substantial compliance with the notice of hearing requirement. The Court applied its holding that the omission of a notice of hearing does not prove fatal to motions if the adverse party actually had the opportunity to be heard.

• Ramos vs. Court of Appeals, 378 Phil. 1198 (1999) — Controlling precedent on the application of res ipsa loquitur in medical negligence cases. The Court relied on its holding that expert medical testimony is dispensed with when the doctrine is availed, because the injury itself provides the proof of negligence.

• Africa, et al. vs. Caltex (Phils.), Inc., et al., 123 Phil. 272 (1966) — Followed as the Philippine case that applied the doctrine of res ipsa loquitur, quoting Espiritu vs. Philippine Power and Development Co. for the elements of the doctrine.

• Scott vs. London & St. Katherine Docks Co., 3 H. &. C. 596 (1865) — The English case that clearly laid down the doctrine of res ipsa loquitur, quoted by the Court for the canonical formulation of the doctrine.

• Philam Life Insurance Company vs. Court of Appeals, 398 Phil. 559 (2000) — Followed for the rule that death certificates are prima facie evidence of facts therein stated, and a duly-registered death certificate is considered a public document whose entries are presumed correct.

• Preysler, Jr. vs. Manila Southcoast Development Corporation, 635 Phil. 598 (2010) — Followed for the principle that a liberal construction of procedural rules is proper where the lapse in the literal observance of a rule of procedure has not prejudiced the adverse party.

• City of Dagupan vs. Maramba, 738 Phil. 71 (2014) — Followed for the rule that the lack of a notice of hearing in a motion for reconsideration may be excused where the adverse party was able to file an opposition.

• Sy vs. Local Government of Quezon City, 710 Phil. 549 (2013) — Followed for the principle that procedural rules may be relaxed for the most persuasive of reasons in order to relieve a litigant of an injustice not commensurate with the degree of his thoughtlessness in not complying with the procedure prescribed.

• Section 5, Rule 15, 1997 Rules on Civil Procedure — The notice of hearing shall be addressed to all parties concerned, and shall specify the time and date of the hearing which must not be later than ten (10) days after the filing of the motion. The Court applied this provision in determining whether the respondents' motion for reconsideration, which lacked a notice of hearing, substantially complied with procedural requirements.

• Section 6, Rule 15, Amended Rules on Civil Procedure (A.M. No. 19-10-20-SC, effective May 1, 2020) — The court may, in the exercise of its discretion, and if deemed necessary for its resolution, call a hearing on the motion. The Court noted this amendment to emphasize that there is no longer a requirement for motions to contain a notice of hearing.

Leonen, SAJ. (Chairperson), Lazaro-Javier, M. Lopez, and Kho, Jr., JJ., concurred.