Transcript
Republic of the Philippines
SUPREME COURT
Manila
THIRD DIVISION
G.R. No. 142625
December 19, 2006
ROGELIO P. NOGALES, for himself and on behalf of the
minors, ROGER ANTHONY, ANGELICA, NANCY, and
MICHAEL CHRISTOPHER, all surnamed
NOGALES, petitioners,
vs.
CAPITOL MEDICAL CENTER, DR. OSCAR ESTRADA, DR.
ELY VILLAFLOR, DR. ROSA UY, DR. JOEL ENRIQUEZ, DR.
PERPETUA LACSON, DR. NOE ESPINOLA, and NURSE J.
DUMLAO, respondents.
DECISION
CARPIO, J.:
The Case
This petition for review1 assails the 6 February 1998
Decision2 and 21 March 2000 Resolution3 of the Court of Appeals
in CA-G.R. CV No. 45641. The Court of Appeals affirmed in
toto the 22 November 1993 Decision4 of the Regional Trial Court
of Manila, Branch 33, finding Dr. Oscar Estrada solely liable for
damages for the death of his patient, Corazon Nogales, while
absolving the remaining respondents of any liability. The Court of
Appeals denied petitioners' motion for reconsideration.
The Facts
Pregnant with her fourth child, Corazon Nogales ("Corazon"), who
was then 37 years old, was under the exclusive prenatal care of
Dr. Oscar Estrada ("Dr. Estrada") beginning on her fourth month
of pregnancy or as early as December 1975. While Corazon was
on her last trimester of pregnancy, Dr. Estrada noted an increase
in her blood pressure and development of leg edema5 indicating
preeclampsia,6 which is a dangerous complication of pregnancy.7
Around midnight of 25 May 1976, Corazon started to experience
mild labor pains prompting Corazon and Rogelio Nogales
("Spouses Nogales") to see Dr. Estrada at his home. After
examining Corazon, Dr. Estrada advised her immediate
admission to the Capitol Medical Center ("CMC").
On 26 May 1976, Corazon was admitted at 2:30 a.m. at the CMC
after the staff nurse noted the written admission request8 of Dr.
Estrada. Upon Corazon's admission at the CMC, Rogelio Nogales
("Rogelio") executed and signed the "Consent on Admission and
Agreement"9 and "Admission Agreement."10 Corazon was then
brought to the labor room of the CMC.
Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of
CMC, conducted an internal examination of Corazon. Dr. Uy then
called up Dr. Estrada to notify him of her findings.
Based on the Doctor's Order Sheet,11 around 3:00 a.m., Dr.
Estrada ordered for 10 mg. of valium to be administered
immediately by intramuscular injection. Dr. Estrada later ordered
the start of intravenous administration of syntocinon admixed with
dextrose, 5%, in lactated Ringers' solution, at the rate of eight to
ten micro-drops per minute.
According to the Nurse's Observation Notes,12 Dr. Joel Enriquez
("Dr. Enriquez"), an anesthesiologist at CMC, was notified at 4:15
a.m. of Corazon's admission. Subsequently, when asked if he
needed the services of an anesthesiologist, Dr. Estrada refused.
Despite Dr. Estrada's refusal, Dr. Enriquez stayed to observe
Corazon's condition.
At 6:00 a.m., Corazon was transferred to Delivery Room No. 1 of
the CMC. At 6:10 a.m., Corazon's bag of water ruptured
spontaneously. At 6:12 a.m., Corazon's cervix was fully dilated. At
6:13 a.m., Corazon started to experience convulsions.
At 6:15 a.m., Dr. Estrada ordered the injection of ten grams of
magnesium sulfate. However, Dr. Ely Villaflor ("Dr. Villaflor"), who
was assisting Dr. Estrada, administered only 2.5 grams of
magnesium sulfate.
At 6:22 a.m., Dr. Estrada, assisted by Dr. Villaflor, applied low
forceps to extract Corazon's baby. In the process, a 1.0 x 2.5 cm.
piece of cervical tissue was allegedly torn. The baby came out in
an apnic, cyanotic, weak and injured condition. Consequently, the
baby had to be intubated and resuscitated by Dr. Enriquez and
Dr. Payumo.
At 6:27 a.m., Corazon began to manifest moderate vaginal
bleeding which rapidly became profuse. Corazon's blood pressure
dropped from 130/80 to 60/40 within five minutes. There was
continuous profuse vaginal bleeding. The assisting nurse
administered hemacel through a gauge 19 needle as a side drip
to the ongoing intravenous injection of dextrose.
At 7:45 a.m., Dr. Estrada ordered blood typing and cross
matching with bottled blood. It took approximately 30 minutes for
the CMC laboratory, headed by Dr. Perpetua Lacson ("Dr.
Lacson"), to comply with Dr. Estrada's order and deliver the
blood.
At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the
Obstetrics-Gynecology Department of the CMC, was apprised of
Corazon's condition by telephone. Upon being informed that
Corazon was bleeding profusely, Dr. Espinola ordered immediate
hysterectomy. Rogelio was made to sign a "Consent to
Operation."13
Due to the inclement weather then, Dr. Espinola, who was fetched
from his residence by an ambulance, arrived at the CMC about an
hour later or at 9:00 a.m. He examined the patient and ordered
some resuscitative measures to be administered. Despite Dr.
Espinola's efforts, Corazon died at 9:15 a.m. The cause of death
was "hemorrhage, post partum."14
On 14 May 1980, petitioners filed a complaint for damages15 with
the Regional Trial Court16 of Manila against CMC, Dr. Estrada, Dr.
Villaflor, Dr. Uy, Dr. Enriquez, Dr. Lacson, Dr. Espinola, and a
certain Nurse J. Dumlao for the death of Corazon. Petitioners
mainly contended that defendant physicians and CMC personnel
were negligent in the treatment and management of Corazon's
condition. Petitioners charged CMC with negligence in the
selection and supervision of defendant physicians and hospital
staff.
For failing to file their answer to the complaint despite service of
summons, the trial court declared Dr. Estrada, Dr. Enriquez, and
Nurse Dumlao in default.17 CMC, Dr. Villaflor, Dr. Uy, Dr.
Espinola, and Dr. Lacson filed their respective answers denying
and opposing the allegations in the complaint. Subsequently, trial
ensued.
After more than 11 years of trial, the trial court rendered judgment
on 22 November 1993 finding Dr. Estrada solely liable for
damages. The trial court ruled as follows:
The victim was under his pre-natal care, apparently, his fault
began from his incorrect and inadequate management and
lack of treatment of the pre-eclamptic condition of his patient.
It is not disputed that he misapplied the forceps in causing
the delivery because it resulted in a large cervical tear which
had caused the profuse bleeding which he also failed to
control with the application of inadequate injection of
magnesium sulfate by his assistant Dra. Ely Villaflor. Dr.
Estrada even failed to notice the erroneous administration by
nurse Dumlao of hemacel by way of side drip, instead of
direct intravenous injection, and his failure to consult a
senior obstetrician at an early stage of the problem.
On the part however of Dra. Ely Villaflor, Dra. Rosa Uy, Dr.
Joel Enriquez, Dr. Lacson, Dr. Espinola, nurse J. Dumlao
and CMC, the Court finds no legal justification to find them
civilly liable.
On the part of Dra. Ely Villaflor, she was only taking orders
from Dr. Estrada, the principal physician of Corazon
Nogales. She can only make suggestions in the manner the
patient maybe treated but she cannot impose her will as to
do so would be to substitute her good judgment to that of Dr.
Estrada. If she failed to correctly diagnose the true cause of
the bleeding which in this case appears to be a cervical
laceration, it cannot be safely concluded by the Court that
Dra. Villaflor had the correct diagnosis and she failed to
inform Dr. Estrada. No evidence was introduced to show that
indeed Dra. Villaflor had discovered that there was laceration
at the cervical area of the patient's internal organ.
On the part of nurse Dumlao, there is no showing that when
she administered the hemacel as a side drip, she did it on
her own. If the correct procedure was directly thru the veins,
it could only be because this was what was probably the
orders of Dr. Estrada.
While the evidence of the plaintiffs shows that Dr. Noe
Espinola, who was the Chief of the Department of Obstetrics
and Gynecology who attended to the patient Mrs. Nogales, it
was only at 9:00 a.m. That he was able to reach the hospital
because of typhoon Didang (Exhibit 2). While he was able to
give prescription in the manner Corazon Nogales may be
treated, the prescription was based on the information given
to him by phone and he acted on the basis of facts as
presented to him, believing in good faith that such is the
correct remedy. He was not with Dr. Estrada when the
patient was brought to the hospital at 2:30 o'clock a.m. So,
whatever errors that Dr. Estrada committed on the patient
before 9:00 o'clock a.m. are certainly the errors of Dr.
Estrada and cannot be the mistake of Dr. Noe Espinola. His
failure to come to the hospital on time was due to fortuitous
event.
On the part of Dr. Joel Enriquez, while he was present in the
delivery room, it is not incumbent upon him to call the
attention of Dr. Estrada, Dra. Villaflor and also of Nurse
Dumlao on the alleged errors committed by them. Besides,
as anesthesiologist, he has no authority to control the
actuations of Dr. Estrada and Dra. Villaflor. For the Court to
assume that there were errors being committed in the
presence of Dr. Enriquez would be to dwell on conjectures
and speculations.
On the civil liability of Dr. Perpetua Lacson, [s]he is a
hematologist and in-charge of the blood bank of the CMC.
The Court cannot accept the theory of the plaintiffs that there
was delay in delivering the blood needed by the patient. It
was testified, that in order that this blood will be made
available, a laboratory test has to be conducted to determine
the type of blood, cross matching and other matters
consistent with medical science so, the lapse of 30 minutes
maybe considered a reasonable time to do all of these
things, and not a delay as the plaintiffs would want the Court
to believe.
Admittedly, Dra. Rosa Uy is a resident physician of the
Capitol Medical Center. She was sued because of her
alleged failure to notice the incompetence and negligence of
Dr. Estrada. However, there is no evidence to support such
theory. No evidence was adduced to show that Dra. Rosa
Uy as a resident physician of Capitol Medical Center, had
knowledge of the mismanagement of the patient Corazon
Nogales, and that notwithstanding such knowledge, she
tolerated the same to happen.
In the pre-trial order, plaintiffs and CMC agreed that
defendant CMC did not have any hand or participation in the
selection or hiring of Dr. Estrada or his assistant Dra. Ely
Villaflor as attending physician[s] of the deceased. In other
words, the two (2) doctors were not employees of the
hospital and therefore the hospital did not have control over
their professional conduct. When Mrs. Nogales was brought
to the hospital, it was an emergency case and defendant
CMC had no choice but to admit her. Such being the case,
there is therefore no legal ground to apply the provisions of
Article 2176 and 2180 of the New Civil Code referring to the
vicarious liability of an employer for the negligence of its
employees. If ever in this case there is fault or negligence in
the treatment of the deceased on the part of the attending
physicians who were employed by the family of the
deceased, such civil liability should be borne by the
attending physicians under the principle of "respondeat
superior".
WHEREFORE, premises considered, judgment is hereby
rendered finding defendant Dr. Estrada of Number 13
Pitimini St. San Francisco del Monte, Quezon City civilly
liable to pay plaintiffs: 1) By way of actual damages in the
amount of P105,000.00; 2) By way of moral damages in the
amount of P700,000.00; 3) Attorney's fees in the amount
of P100,000.00 and to pay the costs of suit.
For failure of the plaintiffs to adduce evidence to support its
[sic] allegations against the other defendants, the complaint
is hereby ordered dismissed. While the Court looks with
disfavor the filing of the present complaint against the other
defendants by the herein plaintiffs, as in a way it has caused
them personal inconvenience and slight damage on their
name and reputation, the Court cannot accepts [sic]
however, the theory of the remaining defendants that
plaintiffs were motivated in bad faith in the filing of this
complaint. For this reason defendants' counterclaims are
hereby ordered dismissed.
SO ORDERED.18
Petitioners appealed the trial court's decision. Petitioners claimed
that aside from Dr. Estrada, the remaining respondents should be
held equally liable for negligence. Petitioners pointed out the
extent of each respondent's alleged liability.
On 6 February 1998, the Court of Appeals affirmed the decision of
the trial court.19 Petitioners filed a motion for reconsideration
which the Court of Appeals denied in its Resolution of 21 March
2000.20
Hence, this petition.
Meanwhile, petitioners filed a Manifestation dated 12 April
200221 stating that respondents Dr. Estrada, Dr. Enriquez, Dr.
Villaflor, and Nurse Dumlao "need no longer be notified of the
petition because they are absolutely not involved in the issue
raised before the [Court], regarding the liability of
[CMC]."22 Petitioners stressed that the subject matter of this
petition is the liability of CMC for the negligence of Dr. Estrada.23
The Court issued a Resolution dated 9 September
200224 dispensing with the requirement to submit the correct and
present addresses of respondents Dr. Estrada, Dr. Enriquez, Dr.
Villaflor, and Nurse Dumlao. The Court stated that with the filing
of petitioners' Manifestation, it should be understood that they are
claiming only against respondents CMC, Dr. Espinola, Dr.
Lacson, and Dr. Uy who have filed their respective comments.
Petitioners are foregoing further claims against respondents Dr.
Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao.
The Court noted that Dr. Estrada did not appeal the decision of
the Court of Appeals affirming the decision of the Regional Trial
Court. Accordingly, the decision of the Court of Appeals, affirming
the trial court's judgment, is already final as against Dr. Oscar
Estrada.
Petitioners filed a motion for reconsideration25 of the Court's 9
September 2002 Resolution claiming that Dr. Enriquez, Dr.
Villaflor and Nurse Dumlao were notified of the petition at their
counsels' last known addresses. Petitioners reiterated their
imputation of negligence on these respondents. The Court denied
petitioners' Motion for Reconsideration in its 18 February 2004
Resolution.26
The Court of Appeals' Ruling
In its Decision of 6 February 1998, the Court of Appeals upheld
the trial court's ruling. The Court of Appeals rejected petitioners'
view that the doctrine in Darling v. Charleston Community
Memorial Hospital27 applies to this case. According to the Court of
Appeals, the present case differs from the Darling case since Dr.
Estrada is an independent contractor-physician whereas
the Darling case involved a physician and a nurse who were
employees of the hospital.
Citing other American cases, the Court of Appeals further held
that the mere fact that a hospital permitted a physician to practice
medicine and use its facilities is not sufficient to render the
hospital liable for the physician's negligence.28 A hospital is not
responsible for the negligence of a physician who is an
independent contractor.29
The Court of Appeals found the cases of Davidson v.
Conole30 and Campbell v. Emma Laing Stevens
Hospital31applicable to this case. Quoting Campbell, the Court of
Appeals stated that where there is no proof that defendant
physician was an employee of defendant hospital or that
defendant hospital had reason to know that any acts of
malpractice would take place, defendant hospital could not be
held liable for its failure to intervene in the relationship of
physician-patient between defendant physician and plaintiff.
On the liability of the other respondents, the Court of Appeals
applied the "borrowed servant" doctrine considering that Dr.
Estrada was an independent contractor who was merely
exercising hospital privileges. This doctrine provides that once the
surgeon enters the operating room and takes charge of the
proceedings, the acts or omissions of operating room personnel,
and any negligence associated with such acts or omissions, are
imputable to the surgeon.32 While the assisting physicians and
nurses may be employed by the hospital, or engaged by the
patient, they normally become the temporary servants or agents
of the surgeon in charge while the operation is in progress, and
liability may be imposed upon the surgeon for their negligent acts
under the doctrine of respondeat superior.33
The Court of Appeals concluded that since Rogelio engaged Dr.
Estrada as the attending physician of his wife, any liability for
malpractice must be Dr. Estrada's sole responsibility.
While it found the amount of damages fair and reasonable, the
Court of Appeals held that no interest could be imposed on
unliquidated claims or damages.
The Issue
Basically, the issue in this case is whether CMC is vicariously
liable for the negligence of Dr. Estrada. The resolution of this
issue rests, on the other hand, on the ascertainment of the
relationship between Dr. Estrada and CMC. The Court also
believes that a determination of the extent of liability of the other
respondents is inevitable to finally and completely dispose of the
present controversy.
The Ruling of the Court
The petition is partly meritorious.
On the Liability of CMC
Dr. Estrada's negligence in handling the treatment and
management of Corazon's condition which ultimately resulted in
Corazon's death is no longer in issue. Dr. Estrada did not appeal
the decision of the Court of Appeals which affirmed the ruling of
the trial court finding Dr. Estrada solely liable for damages.
Accordingly, the finding of the trial court on Dr. Estrada's
negligence is already final.
Petitioners maintain that CMC is vicariously liable for Dr.
Estrada's negligence based on Article 2180 in relation to Article
2176 of the Civil Code. These provisions pertinently state:
Art. 2180. The obligation imposed by article 2176 is
demandable not only for one's own acts or omissions, but
also for those of persons for whom one is responsible.
xxxx
Employers shall be liable for the damages caused by their
employees and household helpers acting within the scope of
their assigned tasks, even though the former are not
engaged in any business or industry.
xxxx
The responsibility treated of in this article shall cease when
the persons herein mentioned prove that they observed all
the diligence of a good father of a family to prevent damage.
Art. 2176. Whoever by act or omission causes damage to
another, there being fault or negligence, is obliged to pay for
the damage done. Such fault or negligence, if there is no
pre-existing contractual relation between the parties, is
called a quasi-delict and is governed by the provisions of this
Chapter.
Similarly, in the United States, a hospital which is the employer,
master, or principal of a physician employee, servant, or agent,
may be held liable for the physician's negligence under the
doctrine of respondeat superior.34
In the present case, petitioners maintain that CMC, in allowing Dr.
Estrada to practice and admit patients at CMC, should be liable
for Dr. Estrada's malpractice. Rogelio claims that he knew Dr.
Estrada as an accredited physician of CMC, though he
discovered later that Dr. Estrada was not a salaried employee of
the CMC.35 Rogelio further claims that he was dealing with CMC,
whose primary concern was the treatment and management of
his wife's condition. Dr. Estrada just happened to be the specific
person he talked to representing CMC.36 Moreover, the fact that
CMC made Rogelio sign a Consent on Admission and Admission
Agreement37 and a Consent to Operation printed on the
letterhead of CMC indicates that CMC considered Dr. Estrada as
a member of its medical staff.
On the other hand, CMC disclaims liability by asserting that Dr.
Estrada was a mere visiting physician and that it admitted
Corazon because her physical condition then was classified an
emergency obstetrics case.38
CMC alleges that Dr. Estrada is an independent contractor "for
whose actuations CMC would be a total stranger." CMC
maintains that it had no control or supervision over Dr. Estrada in
the exercise of his medical profession.
The Court had the occasion to determine the relationship between
a hospital and a consultant or visiting physician and the liability of
such hospital for that physician's negligence in Ramos v. Court of
Appeals,39 to wit:
In the first place, hospitals exercise significant control in the
hiring and firing of consultants and in the conduct of their
work within the hospital premises. Doctors who apply for
"consultant" slots, visiting or attending, are required to
submit proof of completion of residency, their educational
qualifications; generally, evidence of accreditation by the
appropriate board (diplomate), evidence of fellowship in
most cases, and references. These requirements are
carefully scrutinized by members of the hospital
administration or by a review committee set up by the
hospital who either accept or reject the application. This is
particularly true with respondent hospital.
After a physician is accepted, either as a visiting or attending
consultant, he is normally required to attend clinicopathological conferences, conduct bedside rounds for clerks,
interns and residents, moderate grand rounds and patient
audits and perform other tasks and responsibilities, for the
privilege of being able to maintain a clinic in the hospital,
and/or for the privilege of admitting patients into the hospital.
In addition to these, the physician's performance as a
specialist is generally evaluated by a peer review committee
on the basis of mortality and morbidity statistics, and
feedback from patients, nurses, interns and residents. A
consultant remiss in his duties, or a consultant who regularly
falls short of the minimum standards acceptable to the
hospital or its peer review committee, is normally politely
terminated.
In other words, private hospitals, hire, fire and exercise real
control over their attending and visiting "consultant"
staff. While "consultants" are not, technically
employees, a point which respondent hospital asserts in
denying all responsibility for the patient's condition, the
control exercised, the hiring, and the right to terminate
consultants all fulfill the important hallmarks of an
employer-employee relationship, with the exception of
the payment of wages. In assessing whether such a
relationship in fact exists, the control test is
determining. Accordingly, on the basis of the foregoing,
we rule that for the purpose of allocating responsibility
in medical negligence cases, an employer-employee
relationship in effect exists between hospitals and their
attending and visiting physicians. This being the case, the
question now arises as to whether or not respondent hospital
is solidarily liable with respondent doctors for petitioner's
condition.
The basis for holding an employer solidarily responsible for
the negligence of its employee is found in Article 2180 of the
Civil Code which considers a person accountable not only
for his own acts but also for those of others based on the
former's responsibility under a relationship of patria potestas.
x x x40 (Emphasis supplied)
While the Court in Ramos did not expound on the control test,
such test essentially determines whether an employment
relationship exists between a physician and a hospital based on
the exercise of control over the physician as to details.
Specifically, the employer (or the hospital) must have the right to
control both the means and the details of the process by which
the employee (or the physician) is to accomplish his task.41
After a thorough examination of the voluminous records of this
case, the Court finds no single evidence pointing to CMC's
exercise of control over Dr. Estrada's treatment and management
of Corazon's condition. It is undisputed that throughout Corazon's
pregnancy, she was under the exclusive prenatal care of Dr.
Estrada. At the time of Corazon's admission at CMC and during
her delivery, it was Dr. Estrada, assisted by Dr. Villaflor, who
attended to Corazon. There was no showing that CMC had a part
in diagnosing Corazon's condition. While Dr. Estrada enjoyed
staff privileges at CMC, such fact alone did not make him an
employee of CMC.42 CMC merely allowed Dr. Estrada to use its
facilities43 when Corazon was about to give birth, which CMC
considered an emergency. Considering these circumstances, Dr.
Estrada is not an employee of CMC, but an independent
contractor.
The question now is whether CMC is automatically exempt from
liability considering that Dr. Estrada is an independent contractorphysician.
In general, a hospital is not liable for the negligence of an
independent contractor-physician. There is, however, an
exception to this principle. The hospital may be liable if the
physician is the "ostensible" agent of the hospital.44This exception
is also known as the "doctrine of apparent authority."45 In Gilbert
v. Sycamore Municipal Hospital,46the Illinois Supreme Court
explained the doctrine of apparent authority in this wise:
[U]nder the doctrine of apparent authority a hospital can be
held vicariously liable for the negligent acts of a physician
providing care at the hospital, regardless of whether the
physician is an independent contractor, unless the patient
knows, or should have known, that the physician is an
independent contractor. The elements of the action have
been set out as follows:
"For a hospital to be liable under the doctrine of apparent
authority, a plaintiff must show that: (1) the hospital, or its
agent, acted in a manner that would lead a reasonable
person to conclude that the individual who was alleged to be
negligent was an employee or agent of the hospital; (2)
where the acts of the agent create the appearance of
authority, the plaintiff must also prove that the hospital had
knowledge of and acquiesced in them; and (3) the plaintiff
acted in reliance upon the conduct of the hospital or its
agent, consistent with ordinary care and prudence."
The element of "holding out" on the part of the hospital does
not require an express representation by the hospital that the
person alleged to be negligent is an employee. Rather, the
element is satisfied if the hospital holds itself out as a
provider of emergency room care without informing the
patient that the care is provided by independent contractors.
The element of justifiable reliance on the part of the plaintiff
is satisfied if the plaintiff relies upon the hospital to provide
complete emergency room care, rather than upon a specific
physician.
The doctrine of apparent authority essentially involves two factors
to determine the liability of an independent-contractor physician.
The first factor focuses on the hospital's manifestations and is
sometimes described as an inquiry whether the hospital acted in a
manner which would lead a reasonable person to conclude that
the individual who was alleged to be negligent was an employee
or agent of the hospital.47 In this regard, the hospital need not
make express representations to the patient that the treating
physician is an employee of the hospital; rather a
representation may be general and implied.48
The doctrine of apparent authority is a species of the doctrine of
estoppel. Article 1431 of the Civil Code provides that "[t]hrough
estoppel, an admission or representation is rendered conclusive
upon the person making it, and cannot be denied or disproved as
against the person relying thereon." Estoppel rests on this rule:
"Whenever a party has, by his own declaration, act, or omission,
intentionally and deliberately led another to believe a particular
thing true, and to act upon such belief, he cannot, in any litigation
arising out of such declaration, act or omission, be permitted to
falsify it."49
In the instant case, CMC impliedly held out Dr. Estrada as a
member of its medical staff. Through CMC's acts, CMC clothed
Dr. Estrada with apparent authority thereby leading the Spouses
Nogales to believe that Dr. Estrada was an employee or agent of
CMC. CMC cannot now repudiate such authority.
First, CMC granted staff privileges to Dr. Estrada. CMC extended
its medical staff and facilities to Dr. Estrada. Upon Dr. Estrada's
request for Corazon's admission, CMC, through its personnel,
readily accommodated Corazon and updated Dr. Estrada of her
condition.
Second, CMC made Rogelio sign consent forms printed on CMC
letterhead. Prior to Corazon's admission and supposed
hysterectomy, CMC asked Rogelio to sign release forms, the
contents of which reinforced Rogelio's belief that Dr. Estrada was
a member of CMC's medical staff.50 The Consent on Admission
and Agreement explicitly provides:
KNOW ALL MEN BY THESE PRESENTS:
I, Rogelio Nogales, of legal age, a resident of 1974 M. H. Del
Pilar St., Malate Mla., being the
father/mother/brother/sister/spouse/relative/ guardian/or
person in custody of Ma. Corazon, and representing his/her
family, of my own volition and free will, do consent and
submit said Ma. Corazon to Dr. Oscar Estrada (hereinafter
referred to as Physician) for cure, treatment, retreatment, or
emergency measures, that the Physician, personally or
by and through the Capitol Medical Center and/or its
staff, may use, adapt, or employ such means, forms or
methods of cure, treatment, retreatment, or emergency
measures as he may see best and most expedient; that
Ma. Corazon and I will comply with any and all rules,
regulations, directions, and instructions of the
Physician, the Capitol Medical Center and/or its staff;
and, that I will not hold liable or responsible and hereby
waive and forever discharge and hold free the Physician, the
Capitol Medical Center and/or its staff, from any and all
claims of whatever kind of nature, arising from directly or
indirectly, or by reason of said cure, treatment, or
retreatment, or emergency measures or intervention of said
physician, the Capitol Medical Center and/or its staff.
x x x x51 (Emphasis supplied)
While the Consent to Operation pertinently reads, thus:
I, ROGELIO NOGALES, x x x, of my own volition and free
will, do consent and submit said CORAZON NOGALES to
Hysterectomy, by the Surgical Staff and
Anesthesiologists of Capitol Medical Centerand/or
whatever succeeding operations, treatment, or emergency
measures as may be necessary and most expedient; and,
that I will not hold liable or responsible and hereby waive and
forever discharge and hold free the Surgeon, his assistants,
anesthesiologists, the Capitol Medical Center and/or its staff,
from any and all claims of whatever kind of nature, arising
from directly or indirectly, or by reason of said operation or
operations, treatment, or emergency measures, or
intervention of the Surgeon, his assistants,
anesthesiologists, the Capitol Medical Center and/or its
staff.52 (Emphasis supplied)
Without any indication in these consent forms that Dr. Estrada
was an independent contractor-physician, the Spouses Nogales
could not have known that Dr. Estrada was an independent
contractor. Significantly, no one from CMC informed the Spouses
Nogales that Dr. Estrada was an independent contractor. On the
contrary, Dr. Atencio, who was then a member of CMC Board of
Directors, testified that Dr. Estrada was part of CMC's surgical
staff.53
Third, Dr. Estrada's referral of Corazon's profuse vaginal bleeding
to Dr. Espinola, who was then the Head of the Obstetrics and
Gynecology Department of CMC, gave the impression that Dr.
Estrada as a member of CMC's medical staff was collaborating
with other CMC-employed specialists in treating Corazon.
The second factor focuses on the patient's reliance. It is
sometimes characterized as an inquiry on whether the plaintiff
acted in reliance upon the conduct of the hospital or its agent,
consistent with ordinary care and prudence.54
The records show that the Spouses Nogales relied upon a
perceived employment relationship with CMC in accepting Dr.
Estrada's services. Rogelio testified that he and his wife
specifically chose Dr. Estrada to handle Corazon's delivery not
only because of their friend's recommendation, but more
importantly because of Dr. Estrada's "connection with a reputable
hospital, the [CMC]."55 In other words, Dr. Estrada's relationship
with CMC played a significant role in the Spouses Nogales'
decision in accepting Dr. Estrada's services as the obstetriciangynecologist for Corazon's delivery. Moreover, as earlier stated,
there is no showing that before and during Corazon's confinement
at CMC, the Spouses Nogales knew or should have known that
Dr. Estrada was not an employee of CMC.
Further, the Spouses Nogales looked to CMC to provide the best
medical care and support services for Corazon's delivery. The
Court notes that prior to Corazon's fourth pregnancy, she used to
give birth inside a clinic. Considering Corazon's age then, the
Spouses Nogales decided to have their fourth child delivered at
CMC, which Rogelio regarded one of the best hospitals at the
time.56 This is precisely because the Spouses Nogales feared that
Corazon might experience complications during her delivery
which would be better addressed and treated in a modern and big
hospital such as CMC. Moreover, Rogelio's consent in Corazon's
hysterectomy to be performed by a different physician, namely Dr.
Espinola, is a clear indication of Rogelio's confidence in CMC's
surgical staff.
CMC's defense that all it did was "to extend to [Corazon] its
facilities" is untenable. The Court cannot close its eyes to the
reality that hospitals, such as CMC, are in the business of
treatment. In this regard, the Court agrees with the observation
made by the Court of Appeals of North Carolina in Diggs v.
Novant Health, Inc.,57 to wit:
"The conception that the hospital does not undertake to treat
the patient, does not undertake to act through its doctors and
nurses, but undertakes instead simply to procure them to act
upon their own responsibility, no longer reflects the
fact. Present day hospitals, as their manner of operation
plainly demonstrates, do far more than furnish facilities
for treatment. They regularly employ on a salary basis a
large staff of physicians, nurses and internes [sic], as
well as administrative and manual workers, and they
charge patients for medical care and treatment,
collecting for such services, if necessary, by legal
action. Certainly, the person who avails himself of
'hospital facilities' expects that the hospital will attempt
to cure him, not that its nurses or other employees will
act on their own responsibility." x x x (Emphasis supplied)
Likewise unconvincing is CMC's argument that petitioners are
estopped from claiming damages based on the Consent on
Admission and Consent to Operation. Both release forms consist
of two parts. The first part gave CMC permission to administer to
Corazon any form of recognized medical treatment which the
CMC medical staff deemed advisable. The second part of the
documents, which may properly be described as the releasing
part, releases CMC and its employees "from any and all claims"
arising from or by reason of the treatment and operation.
The documents do not expressly release CMC from liability for
injury to Corazon due to negligence during her treatment or
operation. Neither do the consent forms expressly exempt CMC
from liability for Corazon's death due to negligence during such
treatment or operation. Such release forms, being in the nature of
contracts of adhesion, are construed strictly against hospitals.
Besides, a blanket release in favor of hospitals "from any and all
claims," which includes claims due to bad faith or gross
negligence, would be contrary to public policy and thus void.
Even simple negligence is not subject to blanket release in favor
of establishments like hospitals but may only mitigate liability
depending on the circumstances.58 When a person needing
urgent medical attention rushes to a hospital, he cannot bargain
on equal footing with the hospital on the terms of admission and
operation. Such a person is literally at the mercy of the hospital.
There can be no clearer example of a contract of adhesion than
one arising from such a dire situation. Thus, the release forms of
CMC cannot relieve CMC from liability for the negligent medical
treatment of Corazon.
On the Liability of the Other Respondents
Despite this Court's pronouncement in its 9 September
200259 Resolution that the filing of petitioners' Manifestation
confined petitioners' claim only against CMC, Dr. Espinola, Dr.
Lacson, and Dr. Uy, who have filed their comments, the Court
deems it proper to resolve the individual liability of the remaining
respondents to put an end finally to this more than two-decade old
controversy.
a) Dr. Ely Villaflor
Petitioners blame Dr. Ely Villaflor for failing to diagnose the cause
of Corazon's bleeding and to suggest the correct remedy to Dr.
Estrada.60 Petitioners assert that it was Dr. Villaflor's duty to
correct the error of Nurse Dumlao in the administration of
hemacel.
The Court is not persuaded. Dr. Villaflor admitted administering a
lower dosage of magnesium sulfate. However, this was after
informing Dr. Estrada that Corazon was no longer in convulsion
and that her blood pressure went down to a dangerous level.61 At
that moment, Dr. Estrada instructed Dr. Villaflor to reduce the
dosage of magnesium sulfate from 10 to 2.5 grams. Since
petitioners did not dispute Dr. Villaflor's allegation, Dr. Villaflor's
defense remains uncontroverted. Dr. Villaflor's act of
administering a lower dosage of magnesium sulfate was not out
of her own volition or was in contravention of Dr. Estrada's order.
b) Dr. Rosa Uy
Dr. Rosa Uy's alleged negligence consisted of her failure (1) to
call the attention of Dr. Estrada on the incorrect dosage of
magnesium sulfate administered by Dr. Villaflor; (2) to take
corrective measures; and (3) to correct Nurse Dumlao's wrong
method of hemacel administration.
The Court believes Dr. Uy's claim that as a second year resident
physician then at CMC, she was merely authorized to take the
clinical history and physical examination of Corazon.62 However,
that routine internal examination did not ipso facto make Dr. Uy
liable for the errors committed by Dr. Estrada. Further, petitioners'
imputation of negligence rests on their baseless assumption that
Dr. Uy was present at the delivery room. Nothing shows that Dr.
Uy participated in delivering Corazon's baby. Further, it is
unexpected from Dr. Uy, a mere resident physician at that time, to
call the attention of a more experienced specialist, if ever she was
present at the delivery room.
c) Dr. Joel Enriquez
Petitioners fault Dr. Joel Enriquez also for not calling the attention
of Dr. Estrada, Dr. Villaflor, and Nurse Dumlao about their
errors.63 Petitioners insist that Dr. Enriquez should have taken, or
at least suggested, corrective measures to rectify such errors.
The Court is not convinced. Dr. Enriquez is an anesthesiologist
whose field of expertise is definitely not obstetrics and
gynecology. As such, Dr. Enriquez was not expected to correct
Dr. Estrada's errors. Besides, there was no evidence of Dr.
Enriquez's knowledge of any error committed by Dr. Estrada and
his failure to act upon such observation.
d) Dr. Perpetua Lacson
Petitioners fault Dr. Perpetua Lacson for her purported delay in
the delivery of blood Corazon needed.64Petitioners claim that Dr.
Lacson was remiss in her duty of supervising the blood bank staff.
As found by the trial court, there was no unreasonable delay in
the delivery of blood from the time of the request until the
transfusion to Corazon. Dr. Lacson competently explained the
procedure before blood could be given to the patient.65 Taking
into account the bleeding time, clotting time and cross-matching,
Dr. Lacson stated that it would take approximately 45-60 minutes
before blood could be ready for transfusion.66 Further, no
evidence exists that Dr. Lacson neglected her duties as head of
the blood bank.
e) Dr. Noe Espinola
Petitioners argue that Dr. Espinola should not have ordered
immediate hysterectomy without determining the underlying
cause of Corazon's bleeding. Dr. Espinola should have first
considered the possibility of cervical injury, and advised a
thorough examination of the cervix, instead of believing outright
Dr. Estrada's diagnosis that the cause of bleeding was uterine
atony.
Dr. Espinola's order to do hysterectomy which was based on the
information he received by phone is not negligence. The Court
agrees with the trial court's observation that Dr. Espinola, upon
hearing such information about Corazon's condition, believed in
good faith that hysterectomy was the correct remedy. At any rate,
the hysterectomy did not push through because upon Dr.
Espinola's arrival, it was already too late. At the time, Corazon
was practically dead.
f) Nurse J. Dumlao
In Moore v. Guthrie Hospital Inc.,67 the US Court of Appeals,
Fourth Circuit, held that to recover, a patient complaining of
injuries allegedly resulting when the nurse negligently injected
medicine to him intravenously instead of intramuscularly had to
show that (1) an intravenous injection constituted a lack of
reasonable and ordinary care; (2) the nurse injected medicine
intravenously; and (3) such injection was the proximate cause of
his injury.
In the present case, there is no evidence of Nurse Dumlao's
alleged failure to follow Dr. Estrada's specific instructions. Even
assuming Nurse Dumlao defied Dr. Estrada's order, there is no
showing that side-drip administration of hemacel proximately
caused Corazon's death. No evidence linking Corazon's death
and the alleged wrongful hemacel administration was introduced.
Therefore, there is no basis to hold Nurse Dumlao liable for
negligence.
On the Award of Interest on Damages
The award of interest on damages is proper and allowed under
Article 2211 of the Civil Code, which states that in crimes and
quasi-delicts, interest as a part of the damages may, in a proper
case, be adjudicated in the discretion of the court.68
WHEREFORE, the Court PARTLY GRANTS the petition. The
Court finds respondent Capitol Medical Center vicariously liable
for the negligence of Dr. Oscar Estrada. The amounts
of P105,000 as actual damages andP700,000 as moral damages
should each earn legal interest at the rate of six percent (6%) per
annum computed from the date of the judgment of the trial court.
The Court affirms the rest of the Decision dated 6 February 1998
and Resolution dated 21 March 2000 of the Court of Appeals in
CA-G.R. CV No. 45641.
SO ORDERED.
Quisumbing, J., Chairperson, Carpio Morales, Tinga, and
Velasco, Jr., JJ., concur.
Footnotes
1
Under Rule 45 of the Rules of Court.
2
Penned by Associate Justice Artemio G. Tuquero, with
Associate Justices Jorge S. Imperial and Eubulo G. Verzola,
concurring. Rollo, pp. 42-48.
3
Penned by Associate Justice Eubulo G. Verzola, with
Associate Justices Roberto A. Barrios and Eriberto U.
Rosario, Jr., concurring. Id. at 49.
4
Penned by Judge Rodolfo G. Palattao.
5
Edema is the accumulation of excess fluid. It is manifested
by the swelling of the extremities.
(http://www.preeclampsia.org/symptoms.asp)
6
A syndrome occurring in late pregnancy marked by an
increase in blood pressure, swelling of the ankles by fluid,
and the appearance of albumin in the urine, associated with
reduced blood flow to the placenta, therefore putting the
fetus at risk of death, or stillbirth, and putting the mother at
risk of complications from high blood pressure, convulsions
(eclampsia), kidney failure, liver failure and death. Treated
with drugs to lower the blood pressure and to prevent
convulsions, while expediting the delivery of the baby.
(http://www.jansen.com.au/Dictionary_PR.html)
7
Rollo, p. 42.
8
Exh. "A-4," Folder of Exhibits.
9
Exh. "A-1," Folder of Exhibits.
10
Exh. "A-2," Folder of Exhibits.
11
Exh. "A-5," Folder of Exhibits.
12
Exh. "A-8," Folder of Exhibits.
13
Exh. "A-20," Folder of Exhibits.
14
Rollo, p. 43.
15
Docketed as Civil Case No. 131873.
16
Then Court of First Instance.
17
Records, pp. 92, 93.
18
Records, pp. 639-644.
19
Rollo, pp. 42-48.
20
Id. at 49.
21
Id. at 237-240.
22
Id. at 238.
23
Id. at 207.
24
Id. at 258.
25
Id. at 283-285.
26
Id. at 312.
27
33 Ill.2d 326, 211 N.E.2d 253 (1965).
28
Citing Clary v. Hospital Authority of City of Marietta, 106
Ga.App. 134, 126 S.E.2d 470 (1962).
29
Citing Cramer v. Hoffman, 390 F.2d 19, 23
(1968); Holzberg v. Flower and Fifth Ave. Hospitals, 39
A.D.2d 526, 330 N.Y.S.2d 682, 684 (1972); Snelson v.
Margaretville Hospital, 49 A.D.2d 991, 374 N.Y.S.2d 579,
581 (1975).
30
79 A.D.2d 43, 436 N.Y.S.2d 109 (1981).
31
118 A.D.2d 988, 499 N.Y.S.2d 993 (1986).
32
Citing Davis v. Glaze, 182 Ga.App. 18, 354 S.E.2d 845,
849 (1987).
33
Citing Ybarra v. Spangard, 25 Cal.2d 486, 154 P.2d 687
(1944).
34
40A Am.Jur.2d Hospitals and Asylums § 46, 40A
Am.Jur.2d Hospitals and Asylums § 44.
35
TSN, 26 July 1984, pp. 31-32 (Rogelio Nogales).
36
Id. at 43-44.
37
TSN, 4 April 1983, pp. 48-49 (Rogelio Nogales).
38
Records, pp. 43-44.
39
378 Phil. 1198 (1999).
40
Id. at 1240-1241.
41
See Diggs v. Novant Health, Inc., 628 S.E.2d 851 (2006)
citing Hylton v. Koontz, 138 N.C.App. 629 (2000).
42
See Jones v. Tallahassee Memorial Regional Healthcare,
Inc., 923 So.2d 1245 (2006).
43
See Hale v. Sheikholeslam, 724 F.2d 1205 (1984) where
the US Court of Appeals, Fifth Circuit, found the physician an
independent contractor since there is no evidence or
pleading that the doctor received compensation from the
hospital or that the hospital exercised any control over his
treatment of patients. The doctor was merely allowed to use
the facilities of the hospital when, in the doctor's judgment,
hospital care was necessary.
44
Jones v. Philpott, 702 F.Supp. 1210 (1988).
45
Sometimes referred to as the apparent, or ostensible,
agency theory. (King v. Mitchell, 31 A.D.3d 958, 819
N.Y.S.2d 169 [2006]).
46
156 Ill.2d 511, 622 N.E.2d 788 (1993).
47
Diggs v. Novant Health, Inc., supra note 41.
48
Id.
49
De Castro v. Ginete, 137 Phil. 453 (1969), citing Sec. 3,
par. a, Rule 131 of the Rules of Court. See alsoKing v.
Mitchell, 31 A.D.3d 958, 819 N.Y.S.2d 169 (2006) where the
New York Supreme Court, Appellate Division, Third
Department, stated as follows:
As a general proposition, "[a] hospital may not be held for
the acts of an anesthetist who was not an employee of the
hospital, but one of a group of independent
contractors." Vicarious liability for medical malpractice
may be imposed, however, under an apparent, or
ostensible,
agency theory, "or, as it is sometimes called, agency by
estoppel or by holding out." "Essential to the creation of
apparent authority are words or conduct of the principal,
communicated to a third party, that give rise to the
appearance and belief that the agent possesses authority to
act on behalf of the principal." Also, the third party must
reasonably rely upon the appearance of authority created by
the principal. Finally, the third party must accept the services
of the agent in reliance upon the perceived relationship
between the agent and the principal. (emphasis supplied and
internal citations omitted)
50
In Gilbert v. Sycamore Municipal Hospital, supra note 46,
cited in York v. Rush-Presbyterian-St. Luke's Medical
Center (222 Ill.2d 147, 854 N.E.2d 635 [2006]), the Illinois
Supreme Court made a similar observation, thus:
x x x the language employed in the hospital's treatment
consent form could have led plaintiff to reasonably believe
that he would be treated by physicians and employees of the
hospital. We concluded that, upon the record before us, the
plaintiff adduced sufficient evidence to create a genuine
issue of material fact with respect to the reliance element of
the plaintiffs apparent agency claim against the hospital.
51
Exh. "A-1," Folder of Exhibits.
52
Exh. "A-20," Folder of Exhibits.
53
TSN, 17 February 1992, p. 69 (Dr. Franklin Atencio).
54
Diggs v. Novant Health, Inc., supra note 41.
55
TSN, 26 July 1984, pp. 12-13 (Rogelio Nogales).
56
Id. at 37.
57
Supra note 41, citing Rabon v. Rowan Memorial Hospital,
Inc., 269 N.C.1, 152 S.E.2d 485 (1967).
58
Article 1172 of the Civil Code provides:
"Responsibility arising from negligence in the performance of
every kind of obligation is also demandable, but such liability
may be regulated by the courts, according to the
circumstances."
59
Rollo, p. 258.
60
CA rollo, pp. 78-79.
61
Records, p. 76.
62
Id. at 59.
63
CA rollo, p. 89.
64
Id. at 90.
65
TSN, 11 November 1991, pp. 9-12.
66
Id. at 14.
67
403 F.2d 366 (1968).
68
People v. Ocampo, G.R. No. 171731, 11 August 2006,
citing People v. Torellos, 448 Phil. 287, 301 (2003). See
also People v. Duban, G.R. No. 141217, 26 September
2003, 412 SCRA 131 and People v. De Vera, 371 Phil. 563
(1999).