Sps. Bontilao vs. Dr. Gerona

The doctrine of res ipsa loquitur does not apply to hold a surgeon liable for a patient's death during surgery where the instrumentality causing the injury was under the exclusive control of another specialist, such as an anesthesiologist, and where the surgeon exercised the proper standard of care under the circumstances. The doctrine requires that the instrumentality causing the injury be within the exclusive management and control of the defendant, and it must be cautiously applied depending upon the circumstances of each case.

Petitioners Sps. Alfredo and Sherlina Bontilao are the parents of eight-year-old Allen Key Bontilao, who died during an operation performed by respondent Dr. Carlos Gerona, an orthopedic surgeon at the Vicente Gullas Memorial Hospital. The anesthesiologist, Dr. Vicente Jabagat, was separately contracted and chosen by petitioner Sherlina Bontilao. The case involves a medical malpractice claim where the petitioners sought damages against both the surgeon and the anesthesiologist, with the trial court applying the doctrine of res ipsa loquitur and the "captain of the ship" doctrine to establish liability.

On December 28, 1991, respondent Dr. Carlos Gerona, an orthopedic surgeon at the Vicente Gullas Memorial Hospital, treated petitioners' eight-year-old son, Allen Key Bontilao, for a fractured right wrist. Respondent administered a "U-splint" and immobilized Allen's wrist with a cast, then sent Allen home. On June 4, 1992, Allen re-fractured the same wrist and was brought back to the hospital. The x-ray examination showed a complete fracture and displacement of the bone, with the fragments overlapping each other. Respondent performed a closed reduction procedure, with Dr. Vicente Jabagat as the anesthesiologist, and placed Allen's arm in a plaster cast. He allowed Allen to go home after the post-reduction x-ray showed proper bone alignment, but advised petitioner Sherlina Bontilao to bring Allen back for re-tightening of the cast not later than June 15, 1992.

Allen, however, was brought back to the hospital only in June 1992. By then, because the cast had not been re-tightened, a rotational deformity had developed in Allen's arm. The x-ray examination showed that the deformity was caused by a re-displacement of the bone fragments, so it was agreed that an open reduction surgery would be conducted on June 24, 1992 by respondent, again with Dr. Jabagat as the anesthesiologist.

On the said date, Sherlina was allowed to observe the operation behind a glass panel. Dr. Jabagat failed to intubate the patient after five attempts, so anesthesia was administered through a gas mask. Respondent asked Dr. Jabagat if the operation should be postponed given the failure to intubate, but Dr. Jabagat said that it was alright to proceed. Respondent verified that Allen was breathing properly before proceeding with the surgery. As respondent was about to finish the suturing, Sherlina decided to go out of the operating room to make a telephone call and wait for her son. Later, she was informed that her son had died on the operating table. The cause of death was "asphyxia due to congestion and edema of the epiglottis."

Aside from criminal and administrative cases, petitioners filed a complaint for damages against both respondent and Dr. Jabagat in the RTC of Cebu City alleging negligence and incompetence on the part of the doctors. The documentary evidence and testimonies of several witnesses presented in the criminal proceedings were offered and admitted in evidence at the RTC. The RTC decided in favor of the petitioners, holding that the doctrine of res ipsa loquitur was applicable in establishing respondent's liability. The trial court held that respondent and Dr. Jabagat were solidarity liable for they failed to prove that they were not negligent, and that respondent cannot shift the blame solely to Dr. Jabagat as the fault of the latter is also the fault of the former, respondent being the attending physician and being equally in care, custody and control of Allen.

The CA reversed the RTC's ruling, holding that the doctrine of res ipsa loquitur does not apply because the requisites were not satisfied. The CA noted that what was involved was a surgical procedure with all risks attendant, including death, and that it had been established in both the criminal and administrative cases against respondent that Allen's death was the result of the anesthesiologist's negligence and not his. The CA also held that the trial court erred in applying the "captain of the ship" doctrine, noting that unlike in Ramos vs. Court of Appeals, the anesthesiologist was chosen by petitioners and no specific act of negligence was attributable to respondent.

• Applicability of Res Ipsa Loquitur: Petitioners argued that the doctrine of res ipsa loquitur applies to the present case because Allen was healthy, fully conscious, coherent, and ambulant when he went to the hospital to correct a deformed arm, yet he did not survive the operation, which was not even an emergency surgery but a corrective one.
• Liability of Lead Surgeon: Petitioners contended that respondent, being the lead surgeon, should be held liable for the negligence of the physicians and nurses working with him during the operation, invoking the "captain of the ship" doctrine.

• Independent Employment: Respondent posited that he should not be held solidarity liable with Dr. Jabagat as they were employed independently from each other and their services were divided as their best judgment dictated.
• Abandonment of Captain-of-the-Ship Doctrine: Respondent insisted that the captain-of-the-ship doctrine had long been abandoned especially in this age of specialization, and that an anesthesiologist and a surgeon are specialists in their own field and neither one could dictate upon the other.
• Inapplicability of Ramos: Respondent argued that the CA was correct in finding that the Ramos case does not apply to him, as Dr. Jabagat was contracted separately from respondent and was chosen by petitioner Sherlina, respondent was only a few minutes late from the operation, and he waited for the signal of the anesthesiologist to start the procedure.

• Liability for Damages: Whether respondent is liable for damages for Allen's death.
• Applicability of Res Ipsa Loquitur: Whether the doctrine of res ipsa loquitur applies to establish respondent's negligence as the lead surgeon.
• Application of Captain-of-the-Ship Doctrine: Whether respondent, as the lead surgeon, should be held solidarity liable for the negligence of the anesthesiologist under the "captain of the ship" doctrine.

• Liability for Damages: No. Respondent is not liable for damages for Allen's death, as petitioners failed to present substantial evidence of any specific act of negligence on respondent's part or of surrounding facts and circumstances that would lead to the reasonable inference that the untoward consequence was caused by respondent's negligence.
• Applicability of Res Ipsa Loquitur: No. The doctrine of res ipsa loquitur does not apply because the instrumentality causing the injury—the anesthesia and endotracheal tube—was not within respondent's exclusive management and control, as Dr. Jabagat was exclusively in control and management of the anesthesia and the endotracheal tube.
• Application of Captain-of-the-Ship Doctrine: No. The "captain of the ship" doctrine does not apply to hold respondent liable, as the anesthesiologist was chosen by petitioners and no specific act of negligence was attributable to respondent.

• Liability for Damages: The Court found that under the established facts, respondent appears to have observed the proper amount of care required under the circumstances. Having seen that Dr. Jabagat failed in the intubation, respondent inquired from the latter, who was the expert on the matter of administering anesthesia, whether the surgery should be postponed considering the failure to intubate. Respondent further verified that Allen was still breathing by looking at his chest to check that there was excursion before proceeding with the surgery. The Court noted that respondent's decision to continue with the surgery even though there was a failure to intubate does not tend to establish liability, as petitioners failed to present substantial proof that intubation was an indispensable prerequisite for the operation. The expert witness testimony was even to the effect that the anesthesia could be administered by alternative means such as a mask and that the operation could proceed even without intubation. There was also no indication in the records that respondent saw or should have seen that something was wrong as to prompt him to act differently. The anesthesia used was the same anesthesia used in the previous closed reduction procedure, and Allen did not register any adverse reaction to it. Allen started experiencing difficulty in breathing only after the operation, when respondent was already about to jot down his post-operation notes in the adjacent room. Respondent acted promptly and called for other doctors to assist and revive Allen, but to no avail.

• Applicability of Res Ipsa Loquitur: The Court explained that res ipsa loquitur is a rebuttable presumption or inference that the defendant was negligent, which arises only upon proof that the instrumentality causing injury was in the defendant's exclusive control, and that the accident was one which ordinarily does not happen in the absence of negligence. The Court cited the three requisites for the doctrine to apply: (1) the accident is of a kind which ordinarily does not occur in the absence of someone's negligence; (2) it is caused by an instrumentality within the exclusive control of the defendant or defendants; and (3) the possibility of contributing conduct which would make the plaintiff responsible is eliminated. In this case, the instrument which caused the damage or injury was not within respondent's exclusive management and control, as Dr. Jabagat was exclusively in control and management of the anesthesia and the endotracheal tube. The Court also noted that res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied, depending upon the circumstances of each case. In malpractice cases, the doctrine is generally restricted to situations where a layman is able to say, as a matter of common knowledge and observation, that the consequences of professional care were not such as would ordinarily have followed if due care had been exercised.

• Application of Captain-of-the-Ship Doctrine: The Court held that respondent could only supervise Dr. Jabagat to make sure that he was performing his duties, but respondent could not dictate upon Dr. Jabagat the particular anesthesia to administer, the dosage thereof, or that it be administered in any particular way not deemed appropriate by Dr. Jabagat. Respondent's specialization not being in the field of anesthesiology, it would be dangerous for him to substitute his judgment for Dr. Jabagat's decisions in matters that fall appropriately within the scope of Dr. Jabagat's expertise. The Court noted that in civil cases, the burden of proof to be established by preponderance of evidence is on the plaintiff who is asserting the affirmative of an issue, and unless the party asserting the affirmative of an issue sustains the burden of proof, his or her cause will not succeed.

• Res Ipsa Loquitur — A rebuttable presumption or inference that the defendant was negligent, arising upon proof that the instrumentality causing injury was in the defendant's exclusive control and that the accident was one which ordinarily does not happen in the absence of negligence. The requisites are: (1) the accident is of a kind which ordinarily does not occur in the absence of someone's negligence; (2) it is caused by an instrumentality within the exclusive control of the defendant or defendants; and (3) the possibility of contributing conduct which would make the plaintiff responsible is eliminated. The Court applied this doctrine by finding that the second requisite was not satisfied because the anesthesia and endotracheal tube were under the exclusive control of the anesthesiologist, not the surgeon.

• Captain of the Ship Doctrine — A doctrine holding the lead surgeon liable for the negligence of the physicians and nurses working with him during an operation. The Court declined to apply this doctrine, noting that it had been abandoned especially in this age of specialization, and that an anesthesiologist and a surgeon are specialists in their own field and neither one could dictate upon the other.

• "Res ipsa loquitur is a rebuttable presumption or inference that the defendant was negligent. The presumption only arises upon proof that the instrumentality causing injury was in the defendant's exclusive control, and that the accident was one (1) which ordinarily does not happen in the absence of negligence." — This passage defines the doctrine of res ipsa loquitur and its essential requisites, which the Court applied to determine that the doctrine was inapplicable to the respondent surgeon.

• "Here, the respondent could only supervise Dr. Jabagat to make sure that he was performing his duties. But respondent could not dictate upon Dr. Jabagat the particular anesthesia to administer, the dosage thereof, or that it be administered in any particular way not deemed appropriate by Dr. Jabagat." — This passage articulates the Court's reasoning for why the instrumentality causing the injury was not within the respondent's exclusive control, and why the captain-of-the-ship doctrine could not apply.

• "In malpractice cases, the doctrine is generally restricted to situations where a layman is able to say, as a matter of common knowledge and observation, that the consequences of professional care were not as such as would ordinarily have followed if due care had been exercised." — This passage limits the application of res ipsa loquitur in medical malpractice cases to situations where the negligence is obvious to a layman, which was not the case here given the expert testimony about the risks attendant to surgical procedures involving general anesthesia.

• Ramos vs. Court of Appeals, G.R. No. 124354, December 29, 1999, 321 SCRA 584 — Cited as the case relied upon by the trial court in applying the "captain of the ship" doctrine. The Court distinguished this case, noting that unlike in Ramos, the anesthesiologist was chosen by petitioners and no specific act of negligence was attributable to respondent. The Court also cited this case for the proposition that the real question in applying res ipsa loquitur is whether any extraordinary incident or unusual event outside of the routine performance occurred during the operation.

• Batiquin vs. Court of Appeals, G.R. No. 118231, July 5, 1996, 258 SCRA 334 — Cited as authority for the definition of res ipsa loquitur as a rule of evidence whereby negligence of the alleged wrongdoer may be inferred from the mere fact that the accident happened, provided that the character of the accident and circumstances attending it lead reasonably to the belief that in the absence of negligence it would not have occurred.

• Reyes vs. Sisters of Mercy Hospital, G.R. No. 130547, October 3, 2000, 341 SCRA 760 — Cited for the proposition that res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied, depending upon the circumstances of each case.

• Cantre vs. Go, G.R. No. 160889, April 27, 2007, 522 SCRA 547 — Cited for the three requisites of res ipsa loquitur: (1) the accident is of a kind which ordinarily does not occur in the absence of someone's negligence; (2) it is caused by an instrumentality within the exclusive control of the defendant or defendants; and (3) the possibility of contributing conduct which would make the plaintiff responsible is eliminated.

• Alonso vs. Cebu Country Club, Inc., G.R. No. 130876, December 5, 2003, 417 SCRA 115 — Cited for the rule that in civil cases, the burden of proof to be established by preponderance of evidence is on the plaintiff who is asserting the affirmative of an issue.

• Rule 45, 1997 Rules of Civil Procedure — The procedural basis for the petition for review on certiorari filed by the petitioners assailing the Court of Appeals' Decision and Resolution.

Carpio Morales (Chairperson), Peralta, Bersamin, and Sereno, JJ., concurred.