2professional Services, Inc. Vs. Agana.pdf

sponges or other foreign substances in the wound after the incision has been closed is at least prima facienegligence by G.R. No. 126297. January 31, 2007. the operating surgeon. To put it simply, such act is PROFESSIONAL SERVICES, INC., considered so inconsistent with due care as to raise an petitioner, vs.NATIVIDAD and ENRIQUE AGANA, inference of negligence. There are even legions of respondents. authorities to the effect that such act is negligence per se. G.R. No. 126467. January 31, 2007. Same; Same; Same; To the mind of the Court, what was NATIVIDAD and ENRIQUE AGANA, respondents. initially an act of negligence by Dr. Ampil has ripened into a NATIVIDAD (Substituted by her children deliberate wrongful act of deceiving his patient.—Here, Dr. MARCELINO AGANA III, ENRIQUE AGANA, JR., Ampil did not inform Natividad about the missing two EMMA AGANA ANDAYA, JESUS AGANA, and pieces of gauze.Worse, he even misled her that the pain she RAYMUND AGANA) and ENRIQUE AGANA, was experiencing was the ordinary consequence of her petitioners, vs. JUAN FUENTES, respondent. operation. Had he been more candid, Natividad could have G.R. No. 127590. January 31, 2007. taken the immediate and appropriate medical remedy to MIGUEL AMPIL, petitioner, vs. NATIVIDAD AGANA remove the gauzes from her body. To our mind, what was and ENRIQUE AGANA, respondents. initially an act of negligence by Dr. Ampil has ripened into a deliberate wrongful act of deceiving his patient. _______________ Same; Same; Same; Doctrine of Res Ipsa Loquitur; Requisites for the Applicability of the Doctrine.— FIRST DIVISION. Literally, res ipsa loquiturmeans “the thing speaks for 479 itself.” It is the rule that the fact of the occurrence of an VOL. 513, JANUARY 31, 2007 479 injury, taken with the surrounding circumstances, may Professional Services, Inc. vs. Agana permit an inference or raise a presumption of negligence, or Civil Law; Damages; Negligence; The leaving of make out a plaintiff’s prima facie case, and present a sponges or other foreign substances in the wound after the question of fact for defendant to meet with an explanation. incision has been closed is at least prima facie negligence by Stated differently, where the thing which caused the injury, the operating surgeon.— An operation requiring the placing without the fault of the injured, is under the exclusive of sponges in the incision is not complete until the sponges control of the defendant and the injury is such that it are properly removed, and it is settled that the leaving of 478

SUPREME COURT REPORTS ANNOTATED Professional Services, Inc. vs. Agana *

*

*

*

should not have occurred if he, having such control used proper care, it affords reasonable evidence, in the absence of explanation that the injury arose from the defendant’s want of care, and the burden of proof is shifted to him to establish that he has observed due care and diligence. From the foregoing statements of the rule, the requisites for the applicability of the doctrine of res ipsa loquiturare: (1) the occurrence of an injury; (2) the thing which caused the injury was under the control and management of the defendant;(3) the occurrence was such that in the ordinary course of things, would 480

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80 Professional Services, Inc. vs. Agana not have happened if those who had control or management used proper care; and (4) the absence of explanation by the defendant. Of the foregoing requisites, the most instrumental is the “control and management of the thing which caused the injury.” Same; Same; Same; Same; Res ipsa loquitur is not a rule of substantive law, hence, does not per se create or constitute an independent or separate ground of liability, being a mere evidentiary rule.—In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence, does not per se create or constitute an independent or separate ground of liability, being a mere evidentiary rule. In other words, mere invocation and application of the doctrine does not

dispense with the requirement of proof of negligence. Here, the negligence was proven to have been committed by Dr. Ampil and not by Dr. Fuentes. Same; Same; Same; Professionals are considered personally liable for the fault or negligence they commit in the discharge of their duties and their employer cannot be held liable for such fault or negligence.—A prominent civilist commented that professionals engaged by an employer, such as physicians, dentists, and pharmacists, are not “employees” under this article because the manner in which they perform their work is not within the control of the latter (employer). In other words, professionals are considered personally liable for the fault or negligence they commit in the discharge of their duties, and their employer cannot be held liable for such fault or negligence. In the context of the present case, “a hospital cannot be held liable for the fault or negligence of a physician or surgeon in the treatment or operation of patients.” Same; Same; Same; In this jurisdiction, the nature of the relationship between the hospital and the physicians is rendered inconsequential in view of the pronouncement in Ramos vs. Court of Appeals, 321 SCRA 584 (1999), that for purposes of apportioning responsibility in medical negligence cases, an employer-employee relationship in effect exists between hospitals and their attending and visiting physicians.—In our shores, the nature of the relationship between the hospital and the physicians is rendered inconsequential in view of our categorical pronouncement

in Ramos v. Court of Appeals, 321 SCRA 584 (1999), that for purposes of apportioning responsibility in 481

VOL. 513, JANUARY 31, 2007 Professional Services, Inc. vs. Agana medical negligence cases, an employer-employee relationship in effect exists between hospitals and their attending and visiting physicians. Same;Same; Same; PSI’s liability is also anchored upon the agency principle of apparent authority or agency by estoppel and the doctrine of corporate negligence.—But the Ramospronouncement is not our only basis in sustaining PSI’s liability. Its liability is also anchored upon the agency principle of apparent authority or agency by estoppel and the doctrine of corporate negligence which have gained acceptance in the determination of a hospital’s liability for negligent acts of health professionals. The present case serves as a perfect platform to test the applicability of these doctrines, thus, enriching our jurisprudence. Apparent authority, or what is sometimes referred to as the “holding out” theory, or doctrine of ostensible agency or agency by estoppel, has its origin from the law of agency. It imposes liability, not as the result of the reality of a contractual relationship, but rather because of the actions of a principal or an employer in somehow misleading the public into believing that the relationship or the authority exists. The concept is

essentially one of estoppel and has been explained in this manner: “The principal is bound by the acts of his agent with the apparent authority which he knowingly permits 48 the agent to assume, or which he holds the agent out to the 1 public as possessing. The question in every case is whether the principal has by his voluntary act placed the agent in such a situation that a person of ordinary prudence, conversant with business usages and the nature of the particular business, is justified in presuming that such agent has authority to perform the particular act in question. Same; Same; Same; In cases where it can be shown that a hospital, by its actions, has held out a particular physician as its agent and/or employee and that a patient has accepted treatment from that physician in the reasonable belief that it is being rendered in behalf of the hospital, then the hospital will be liable for the physician’s negligence.—The applicability of apparent authority in the field of hospital liability was upheld long time ago in Irving v. Doctor Hospital of Lake Worth, Inc., 415 So. 2d 55 (1982). There, it was explicitly stated that “there does not appear to be any rational basis for excluding the concept of apparent authority from the field of hospital liability.” Thus, in cases where it can be shown that a hospital, by its actions, has held out a particular physician as its agent and/or employee and 482

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82 Professional Services, Inc. vs. Agana that a patient has accepted treatment from that physician in the reasonable belief that it is being rendered in behalf of the hospital, then the hospital will be liable for the physician’s negligence. Same; Same; Same; By accrediting Dr. Ampil and Dr. Fuentes and publicly advertising their qualifications, the hospital created the impression that they were its agents, authorized to perform medical or surgical services for its patients.—In this case, PSI publicly displays in the lobby of the Medical City Hospital the names and specializations of the physicians associated or accredited by it, including those of Dr. Ampil and Dr. Fuentes. We concur with the Court of Appeals’ conclusion that it “is now estopped from passing all the blame to the physicians whose names it proudly paraded in the public directory leading the public to believe that it vouched for their skill and competence.” Indeed, PSI’s act is tantamount to holding out to the public that Medical City Hospital, through its accredited physicians, offers quality health care services. By accrediting Dr. Ampil and Dr. Fuentes and publicly advertising their qualifications, the hospital created the impression that they were its agents, authorized to perform medical or surgical services for its patients. As expected, these patients, Natividad being one of them, accepted the services on the reasonable belief that such were being

rendered by the hospital or its employees, agents, or servants.

PETITION for review on certiorari of the decisions of the Court of Appeals. The facts are stated in the opinion of the Court. Bengzon, Narciso, Cudala, Pecson, Bengzon & Jimenez for petitioner Professional Services, Inc. Enrique Agana & Associates for petitioners Natividad and Enrique Agana. The Law Firm of Raymundo M. Armovit for petitioner Miguel Ampil. Agcaoili Law Offices collaborating counsel for Heirs of Natividad Agana. Benjamin M. Tongol for Juan Fuentes. 483

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483

SANDOVAL-GUTIERREZ, J.: Hospitals, having undertaken one of mankind’s most important and delicate endeavors, must assume the grave responsibility of pursuing it with appropriate care. The care and service dispensed through this high trust, however technical, complex and esoteric its character may be, must meet standards of responsibility commensurate with the undertaking to preserve and protect the health, and indeed, the very lives of those placed in the hospital’s keeping. 1

Assailed in these three consolidated petitions for review on certiorari is the Court of Appeals’ Decision dated September 6, 1996 in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198 affirming with modification the Decision dated March 17, 1993 of the Regional Trial Court (RTC), Branch 96, Quezon City in Civil Case No. Q-43322 and nullifying its Order dated September 21, 1993. The facts, as culled from the records, are: On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital (Medical City Hospital) because of difficulty of bowel movement and bloody anal discharge. After a series of medical examinations, Dr. Miguel Ampil, petitioner in G.R. No. 127590, diagnosed her to be suffering from “cancer of the sigmoid.” 2

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Professional Services, Inc. vs. Agana

On April 11, 1984, Dr. Ampil, assisted by the medical staff of the Medical City Hospital, performed an anterior resection surgery on Natividad. He found that the malignancy in her sigmoid area had spread on her left ovary, necessitating the removal of certain portions of it. Thus, Dr. Ampil obtained the consent of Natividad’s husband, Enrique Agana, to permit Dr. Juan Fuentes, respondent in G.R. No. 126467, to perform hysterectomy on her. After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed the operation and closed the incision. However, the operation appeared to be flawed. In the corresponding Record of Operation dated April 11, 1984, the attending nurses entered these remarks: 4

“sponge count lacking 2 _______________

1

“announced to surgeon searched (sic) done but to no avail

Beeck v. Tucson General Hospital, 500 P. 2d 1153 (1972), citingDarling v.

Charleston Community Memorial Hospital, 33 Ill. 2d 326, 211 N.E. 2d 253. 2

Penned by Associate Justice Cancio C. Garcia (now a member of the Supreme

Court) and concurred in by Associate Justices Eugenio S. Labitoria and Artemio G. Tuquero (both retired), Rollo, G.R. No. 126297, pp. 36-51; 126467, pp. 27-42; 127590, pp. 23-38. 3

Penned by Judge Lucas P. Bersamin (now Justice of the Court of

Appeals), Rollo, G.R. No. 126647, pp. 69-83.

484

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continue for closure.”

On April 24, 1984, Natividad was released from the hospital. Her hospital and medical bills, including the doctors’ fees, amounted to P60,000.00. After a couple of days, Natividad complained of excruciating pain in her anal region. She consulted both Dr. Ampil and Dr. Fuentes about it. They told her that the pain was the natural consequence of the surgery. Dr. Ampil then recommended that she consult

an oncologist to examine the cancerous nodes which were not removed during the operation. On May 9, 1984, Natividad, accompanied by her husband, went to the United States to seek further treatment. After four months of consultations and laboratory examinations, Natividad was told she was free of cancer. Hence, she was advised to return to the Philippines.

foul-smelling gauze measuring 1.5 inches in width which badly infected her vaginal vault. A recto-vaginal fistula had formed in her reproductive organs which forced stool to excrete through the vagina. Another surgical operation was needed to remedy the damage. Thus, in October 1984, Natividad underwent another surgery. On November 12, 1984, Natividad and her husband filed with the RTC, Branch 96, Quezon City a _______________ complaint for damages against the Professional Services, Inc. (PSI), owner of the Medical City The medical staff was composed of physicians, both residents and interns, as Hospital, Dr. Ampil, and Dr. Fuentes, docketed as well as nurses. Civil Case No. Q-43322. They alleged that the latter 485 are liable for negligence for leaving two pieces of gauze VOL. 513, JANUARY 31, 2007 485 inside Natividad’s body and malpractice for concealing Professional Services, Inc. vs. Agana their acts of negligence. On August 31, 1984, Natividad flew back to the Meanwhile, Enrique Agana also filed with the Philippines, still suffering from pains. Two weeks Professional Regulation Commission (PRC) an thereafter, her daughter found a piece of gauze administrative complaint for gross negligence and protruding from her vagina. Upon being informed malpractice against Dr. Ampil and Dr. Fuentes, about it, Dr. Ampil proceeded to her house where he docketed as Administrative Case No. 1690. The PRC managed to extract by hand a piece of gauze Board of Medicine heard the case only with respect to measuring 1.5 inches in width. He then assured her Dr. Fuentes because it failed to acquire jurisdiction that the pains would soon vanish. over Dr. Ampil who was then in the United States. Dr. Ampil’s assurance did not come true. Instead, On February 16, 1986, pending the outcome of the the pains intensified, prompting Natividad to seek above cases, Natividad died and was duly substituted treatment at the Polymedic General Hospital. While by her abovenamed children (the Aganas). confined there, Dr. Ramon Gutierrez detected the 486 presence of another foreign object in her vagina—a 4

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SUPREME COURT REPORTS ANNOTATED Professional Services, Inc. vs. Agana

4. 5.Legal interest on items 1 (a), (b), and (c); 2; and 3 hereinabove, from date of filing of the complaint until full payment; and

On March 17, 1993, the RTC rendered its Decision in favor of the Aganas, finding PSI, Dr. Ampil and Dr. Fuentes liable for negligence and malpractice, the decretal part of which reads: “WHEREFORE, judgment is hereby rendered for the plaintiffs ordering the defendants PROFESSIONAL SERVICES, INC., DR. MIGUEL AMPIL and DR. JUAN FUENTES to pay to the plaintiffs, jointly and severally, except in respect of the award for exemplary damages and the interest thereon which are the liabilities of defendants Dr. Ampil and Dr. Fuentes only, as follows:

1. a.The equivalent in Philippine Currency of the total of at

the

rate

of

P21.60-US$1.00,

as

reimbursement of actual expenses incurred in the United States of America; 2. b.The sum of P4,800.00 as travel taxes of plaintiffs and their physician daughter; 3. c.The total sum of P45,802.50, representing the cost of hospitalization at Polymedic Hospital, medical fees, and cost of the saline solution; 1. 2.As moral damages, the sum of P2,000,000.00; 2. 3.As exemplary damages, the sum of P300,000.00; 3. 4.As attorney’s fees, the sum of P250,000.00;

SO ORDERED.”

Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of Appeals, docketed as CAG.R. CV No. 42062. Incidentally, on April 3, 1993, the Aganas filed with the RTC a motion for a partial execution of its Decision, which was granted in an Order dated May 11, 1993. Thereafter, the sheriff levied upon certain properties of Dr. Ampil and sold 487

1. 1.As actual damages, the following amounts:

US$19,900.00

5. 6.Costs of suit.

VOL. 513, JANUARY 31, 2007 Professional Services, Inc. vs. Agana

them for P451,275.00 and delivered the amount to the Aganas. Following their receipt of the money, the Aganas entered into an agreement with PSI and Dr. Fuentes to indefinitely suspend any further execution of the RTC Decision. However, not long thereafter, the Aganas again filed a motion for an alias writ of execution against the properties of PSI and Dr. Fuentes. On September 21, 1993, the RTC granted the motion and issued the corresponding writ, prompting Dr. Fuentes to file with the Court of Appeals a petition for certiorari and prohibition, with prayer for

487

preliminary injunction, docketed as CA-G.R. SP No. 32198. During its pendency, the Court of Appeals issued a Resolution dated October 29, 1993 granting Dr. Fuentes’ prayer for injunctive relief. On January 24, 1994, CA-G.R. SP No. 32198 was consolidated with CA-G.R. CV No. 42062. Meanwhile, on January 23, 1995, the PRC Board of Medicine rendered its Decision in Administrative Case No. 1690 dismissing the case against Dr. Fuentes. The Board held that the prosecution failed to show that Dr. Fuentes was the one who left the two pieces of gauze inside Natividad’s body; and that he concealed such fact from Natividad. 5

6

On September 6, 1996, the Court of Appeals rendered its Decision jointly disposing of CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198, thus: “WHEREFORE, except for the modification that the case against defendant-appellant Dr. Juan Fuentes is hereby DISMISSED, and with the pronouncement that defendant-appellant Dr. Miguel Ampil is liable to

reimburse

defendant-appellant Professional

Services,

Inc.,

whatever amount the latter will pay or had paid to the plaintiffsappellees, the decision appealed from is herebyAFFIRMED and the instant appeal DISMISSED. Concomitant with the above, the petition for certiorari and prohibition filed by herein defendant-appellant Dr. Juan Fuentes in CAG.R. SP No. 32198 is hereby GRANTED and the challenged order of the respondent judge dated September 21, 1993, as well as the alias writ of

_______________

5

execution issued pursuant thereto are hereby NULLIFIED and SET

The dispositive portion reads:

“WHEREFORE, let a writ of preliminary injunction be issued upon petitioner’s posting of bond in the amount of P20,000.00, ENJOINING public respondents from implementing the questioned order dated September 21, 1993 and from further taking any action in Civil Case No. Q-43322 entitled ‘Natividad G. Agana, et al., plaintiffs, versus Professional Services, Inc., et al., defendants’ pending resolution of the instant petition. SO ORDERED.” See Rollo, G.R. No. 126297, p. 42. 6

Rollo of G.R. No. 126467, pp. 84-89.

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SUPREME COURT REPORTS ANNOTATED Professional Services, Inc. vs. Agana

ASIDE. The bond posted by the petitioner in connection with the writ of preliminary injunction issued by this Court on November 29, 1993 is hereby cancelled. Costs

against

defendants-appellants Dr.

Miguel

Ampil andProfessional Services, Inc. SO ORDERED.”

Only Dr. Ampil filed a motion for reconsideration, but it was denied in a Resolution dated December 19, 1996. Hence, the instant consolidated petitions. In G.R. No. 126297, PSI alleged in its petition that the Court of Appeals erred in holding that: (1) it is estopped from raising the defense that Dr. Ampil is not 7

its employee;(2) it is solidarily liable with Dr. Ampil; and (3) it is not entitled to its counterclaim against the Aganas. PSI contends that Dr. Ampil is not its employee, but a mere consultant or independent contractor. As such, he alone should answer for his negligence. _______________

7

Rollo of G.R. No. 127590, p. 40.

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In G.R. No. 126467, the Aganas maintain that the Court of Appeals erred in finding that Dr. Fuentes is not guilty of negligence or medical malpractice, invoking the doctrine ofres ipsa loquitur. They contend that the pieces of gauze areprima facie proofs that the operating surgeons have been negligent. Finally, in G.R. No. 127590, Dr. Ampil asserts that the Court of Appeals erred in finding him liable for negligence and malpractice sans evidence that he left the two pieces of gauze in Natividad’s vagina. He pointed to other probable causes, such as: (1) it was Dr. Fuentes who used gauzes in performing the hysterectomy; (2) the attending nurses’ failure to properly count the gauzes used during surgery; and (3) the medical intervention of the American

doctors who examined Natividad in the United States of America. For our resolution are these three vital issues: first, whether the Court of Appeals erred in holding Dr. Ampil liable for negligence and malpractice; second, whether the Court of Appeals erred in absolving Dr. Fuentes of any liability; and third, whether PSI may be held solidarily liable for the negligence of Dr. Ampil. I—G.R. No. 127590 Whether the Court of Appeals Erred in Holding Dr. Ampil Liable for Negligence and Malpractice.

489 Dr. Ampil, in an attempt to absolve himself, gears the

Court’s attention to other possible causes of Natividad’s detriment. He argues that the Court should not discount either of the following possibilities: first, Dr. Fuentes left the gauzes in Natividad’s body after performing hysterectomy; second, the attending nurses erred in counting the gauzes; and third, the American doctors were the ones who placed the gauzes in Natividad’s body. Dr. Ampil’s arguments are purely conjectural and without basis. Records show that he did not present any evidence to prove that the American doctors were the ones who put or left 490

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SUPREME COURT REPORTS ANNOTATED Professional Services, Inc. vs. Agana

the gauzes in Natividad’s body. Neither did he submit evidence to rebut the correctness of the record of operation, particularly the number of gauzes used. As to the alleged negligence of Dr. Fuentes, we are mindful that Dr. Ampil examined his (Dr. Fuentes’) work and found it in order. The glaring truth is that all the major circumstances, taken together, as specified by the Court of Appeals, directly point to Dr. Ampil as the negligent party, thus: First, it is not disputed that the surgeons used gauzes as sponges to control the bleeding of the patient during the surgical operation. Second, immediately after the operation, the nurses who assisted in the surgery noted in their report that the ‘sponge count (was) lacking 2’; that such anomaly was ‘announced to surgeon’ and that a ‘search was done but to no avail’ prompting Dr. Ampil to ‘continue for closure’ x x x. Third, after the operation, two (2) gauzes were extracted from the same spot of the body of Mrs. Agana where the surgery was performed.

An operation requiring the placing of sponges in the incision is not complete until the sponges are properly removed, and it is settled that the leaving of sponges or other foreign substances in the wound after the incision has been closed is at least prima facie negligence by the operating surgeon. To put it simply, such act is considered so inconsistent with due care as to raise an inference of negligence. There are 8

even legions of authorities to the effect that such act is negligence per se. 9

_______________

8

Rule v. Cheeseman, 317 P. 2d 472 (1957), citing Russel v. Newman, 116 Kan.

268 P. 752; Bernsden v. Johnson, 174 Kan. 230, 255 P. 2d 1033. 9

Smith v. Zeagler, 157 So. 328 Fla. (1934), citing Ruth v. Johnson, (C.C.A.)

172 F. 191; Reeves v. Lutz, 179 Mo. App. 61, 162 S.W. 280;Rayburn v. Day, 126 Or. 135, 68 P. 1002, 59 A.L.R. 1062; Wynne v. Harvey, 96 Wash. 379, 165 P. 67; Harris v. Fall (C.C.A.), 177 F. 79,

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VOL. 513, JANUARY 31, 2007 Professional Services, Inc. vs. Agana

Of course, the Court is not blind to the reality that there are times when danger to a patient’s life precludes a surgeon from further searching missing sponges or foreign objects left in the body. But this does not leave him free from any obligation. Even if it has been shown that a surgeon was required by the urgent necessities of the case to leave a sponge in his patient’s abdomen, because of the dangers attendant upon delay, still, it is his legal duty to so inform his patient within a reasonable time thereafter by advising her of what he had been compelled to do. This is in order that she might seek relief from the effects of the foreign object left in her body as her condition might permit. The ruling in Smith v. Zeagler is explicit, thus: 10

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Professional Services, Inc. vs. Agana

“The removal of all sponges used is part of a surgical operation, and when a physician or surgeon fails to remove a sponge he has placed in his patient’s body that should be removed as part of the operation, he thereby leaves his operation uncompleted andcreates a new condition which imposes upon him the legal duty of calling the new condition to his patient’s attention, and endeavoring with the means he has at hand to minimize and avoid untoward results likely to ensue therefrom.”

Here, Dr. Ampil did not inform Natividad about the missing two pieces of gauze. Worse, he even misled her that the pain she was experiencing was the ordinary consequence of her operation. Had he been more candid, Natividad could have taken the immediate and appropriate medical remedy to remove the gauzes from her body. To our mind, what was initially an act of negligence by Dr. Ampil has ripened into a deliberate wrongful act of deceiving his patient. This is a clear case of medical malpractice or more appropriately, medical negligence. To successfully pursue this kind of case, a patient must only prove that a health care provider

either failed to do something which a reasonably prudent health care provider would have done, or that he did something that a reasonably prudent provider would not have done; and that failure or action caused injury to the patient. Simply put, the elements are duty, breach, injury and proximate causation. Dr, Ampil, as the lead surgeon, had the duty to remove all foreign objects, such as gauzes, from Natividad’s body before closure of the incision. When he failed to do so, it was his duty to inform Natividad about it. Dr. Ampil breached both duties. Such breach caused injury to Natividad, necessitating her further examination by American doctors and another surgery. That Dr. Ampil’s negligence is the proximate cause of Natividad’s injury could be traced from his act of closing the incision despite the information given by the attending nurses that two pieces of gauze were still missing. That they were later on extracted from Natividad’s vagina established the causal link between Dr. Ampil’s negligence and the injury. And what further aggravated such injury was 11

12

_______________ _______________ 27 L.R.A. (N.S.) 1174; Moore v. Ivey, (Tex. Civ. App.) 264 S.W. 283; 21 R.C. L. 388.

11

10

157 So. 328 Fla. (1934)

492

492

SUPREME COURT REPORTS ANNOTATED

769.

Garcia-Rueda v. Pascasio, G.R. No. 118141, September 5, 1997, 278 SCRA

Literally, res ipsa loquitur means “the thing speaks for itself.” It is the rule that the fact of the occurrence Court laid down the following definition of proximate cause in this jurisdiction as of an injury, taken with the surrounding follows: circumstances, may permit an inference or raise a [T]hat cause, which, in natural and continuous sequence unbroken by any efficient presumption of negligence, or make out a intervening cause, produces the injury and without which the result would not have occurred. plaintiff’s prima facie case, and present a question of And more comprehensively, the proximate cause is that acting first and producing the injury, fact for defendant to meet with an explanation. Stated either immediately or by setting other events in motion, all constituting a natural and differently, where the thing which caused the injury, continuous chain of events, each having a close causal connection with the immediate without the fault of the injured, is under the exclusive predecessor, the final event in the chain immediately effecting the injury as a natural and control of the defendant and the injury is such that it probable result of the cause which first acted, under which circumstances that the person should not have occurred if he, having such control responsible for the first event should, as an ordinarily prudent and intelligent person, have used proper care, it affords reasonable evidence, in the reasonable ground to expect at the moment of his act or default that an injury to some person absence of explanation that the injury arose from the might probably result therefrom. defendant’s want of care, and the burden of proof is 493 VOL. 513, JANUARY 31, 2007 493 shifted to him to establish that he has observed due Professional Services, Inc. vs. Agana care and diligence. From the foregoing statements of the rule, the his deliberate concealment of the missing gauzes from requisites for the applicability of the doctrine of res the knowledge of Natividad and her family. II—G.R. No. 126467 ipsa loquitur are:(1) the occurrence of an injury; (2) the Whether the Court of Appeals Erred in Absolving Dr. thing which caused the injury was under the control Fuentes of any Liability and management of the defenThe Aganas assailed the dismissal by the trial court of _______________ the case against Dr. Fuentes on the ground that it is contrary to the doctrine of res ipsa loquitur. According Ramos v. Court of Appeals, G.R. No. 124354, December 29, 1999, 321 SCRA to them, the fact that the two pieces of gauze were left 584. inside Natividad’s body is a prima facie evidence of Dr. Africa v. Caltex (Phils.) Inc., 123 Phil. 280; 16 SCRA 448 (1966). Fuentes’ negligence. 494 We are not convinced. 12

In the leading case of Vda. de Bataclan v. Medina, (102 Phil. 181[1957]), this

13

14

13

14

494

SUPREME COURT REPORTS ANNOTATED

Professional Services, Inc. vs. Agana

dant; (3) the occurrence was such that in the ordinary course of things, would not have happened if those who had control or management used proper care; and (4) the absence of explanation by the defendant. Of the foregoing requisites, the most instrumental is the “control and management of the thing which caused the injury.” We find the element of “control and management of the thing which caused the injury” to be wanting. Hence, the doctrine of res ipsa loquitur will not lie. It was duly established that Dr. Ampil was the lead surgeon during the operation of Natividad. He requested the assistance of Dr. Fuentes only to perform hysterectomy when he (Dr. Ampil) found that the malignancy in her sigmoid area had spread to her left ovary. Dr. Fuentes performed the surgery and thereafter reported and showed his work to Dr. Ampil. The latter examined it and finding everything to be in order, allowed Dr. Fuentes to leave the operating room. Dr. Ampil then resumed operating on Natividad. He was about to finish the procedure when the attending nurses informed him that two pieces of gauze were missing. A “diligent search” was conducted, but the misplaced gauzes were not found. Dr. Ampil then directed that the incision be closed. During this entire period, Dr. Fuentes was no longer in the operating room and had, in fact, left the hospital.

Under the “Captain of the Ship” rule, the operating surgeon is the person in complete charge of the surgery room and all personnel connected with the operation. Their duty is to obey his orders. As stated before, Dr. Ampil was the lead surgeon. In other words, he was the “Captain of the Ship.” That he discharged such role is evident from his following 16

15

_______________

15

Ranos v. Court of Appeals, supra. In Ramos, the phrase used is “control of

the instrumentality which caused the damage,” citing St. John’s Hospital and School of Nursing v. Chapman, 434 P2d 160 (1967). 16

Rural Educational Assn v. Bush, 42 Tenn. App. 34, 298 S.W. 2d 761 (1956).

495

VOL. 513, JANUARY 31, 2007 Professional Services, Inc. vs. Agana

conduct: (1) calling Dr. Fuentes to perform a hysterectomy;(2) examining the work of Dr. Fuentes and finding it in order; (3) granting Dr. Fuentes’ permission to leave; and (4)ordering the closure of the incision. To our mind, it was this act of ordering the closure of the incision notwithstanding that two pieces of gauze remained unaccounted for, that caused injury to Natividad’s body. Clearly, the control and management of the thing which caused the injury was in the hands of Dr. Ampil, not Dr. Fuentes. In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence, does not per se create or

495

constitute an independent or separate ground of liability, being a mere evidentiary rule. In other words, mere invocation and application of the doctrine does not dispense with the requirement of proof of negligence. Here, the negligence was proven to have been committed by Dr. Ampil and not by Dr. Fuentes. 17

III—G.R. No. 126297 Whether PSI Is Liable for the Negligence of Dr. Ampil

The third issue necessitates a glimpse at the historical development of hospitals and the resulting theories concerning their liability for the negligence of physicians. Until the mid-nineteenth century, hospitals were generally charitable institutions, providing medical services to the lowest classes of society, without regard for a patient’s ability to pay. Those who could afford medical treatment were usually treated at home by their doctors. However, the days of house calls and philanthropic health care are over. The modern health care industry continues to distance itself from its 18

19

_______________

17

Ramos v. Court of Appeals, supra at footnote 13.

18

Levin, Hospital Vicarious Liability for Negligence by Independent Contractor

Physicians: A New Rule for New Times, October 17, 2005. 19

Id.

charitable past and has experienced a significant conversion from a not-for-profit health care to forprofit hospital businesses. Consequently, significant changes in health law have accompanied the businessrelated changes in the hospital industry. One important legal change is an increase in hospital liability for medical malpractice. Many courts now allow claims for hospital vicarious liability under the theories of respondeat superior, apparent authority, ostensible authority, or agency by estoppel. In this jurisdiction, the statute governing liability for negligent acts is Article 2176 of the Civil Code, which reads: 20

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.

A derivative of this provision is Article 2180, the rule governing vicarious liability under the doctrine ofrespondeat superior, thus: 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. xxx

xxx

The owners and managers of an establishment or enterprise are

496

496

Professional Services, Inc. vs. Agana

SUPREME COURT REPORTS ANNOTATED

likewise responsible for damages caused by their employees in the

The foregoing view is grounded on the traditional notion that the professional status and the very nature of the physician’s calling preclude him from being classed as an agent or employee of a hospital, whenever he acts in a professional capacity. It has been said that medical practice strictly involves highly developed and specialized knowledge, such that physicians are generally free to exercise their own skill

service of the branches in which the latter are employed or on the occasion of their functions. 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. xxx

xxx

22

_______________

20

23

Id.

497

_______________

VOL. 513, JANUARY 31, 2007 Professional Services, Inc. vs. Agana The responsibility treated of in this article shall cease when the persons

497 21

Tolentino, The Civil Code of the Philippines, Volume V, 1992 Ed., p. 616.

22

Arkansas M.R. Co. v. Pearson, 98 Ark. 442, 153 SW 595 (1911);Runyan v.

herein mentioned prove that they observed all the diligence of a good

Goodrum, 147 Ark. 281, 228 SW 397, 13 ALR 1403 (1921);Rosane v. Senger, 112

father of a family to prevent damage.

Colo. 363, 149 P. 2d 372 (superseded by statute on other grounds); Moon v. Mercy

A prominent civilist commented that professionals engaged by an employer, such as physicians, dentists, and pharmacists, are not “employees” under this article because the manner in which they perform their work is not within the control of the latter (employer). In other words, professionals are considered personally liable for the fault or negligence they commit in the discharge of their duties, and their employer cannot be held liable for such fault or negligence. In the context of the present case, “a hospital cannot be held liable for the fault or negligence of a physician or surgeon in the treatment or operation of patients.” 21

Hosp., 150 Col. 430, 373 P. 2d 944 (1962);Austin v. Litvak, 682 P. 2d 41, 50 ALR 4th 225 (1984); Western Ins. Co. v. Brochner, 682 P. 2d 1213 (1983); Rodriguez v. Denver, 702 P. 2d 1349 (1984). 23

Arkansas M.R. Co. v. Pearson, Id.; Nieto v. State, 952 P. 2d 834 (1997). But

see Beeck v. Tucson General Hosp., 18 Ariz. App. 165, 500 P. 2d 1153 (1972); Paintsville Hosp. Co., 683 SW 2d 255 (1985); Kelley v. Rossi, 395 Mass. 659, 481 NE 2d 1340 (1985) which held that a physician’s professional status does not prevent him or her from being a servant or agent of the hospital.

498

498

SUPREME COURT REPORTS ANNOTATED Professional Services, Inc. vs. Agana

and judgment in rendering medical services sans interference. Hence, when a doctor practices medicine 24

in a hospital setting, the hospital and its employees are deemed to subserve him in his ministrations to the patient and his actions are of his own responsibility. The case of Schloendorff v. Society of New York Hospital was then considered an authority for this view. The “Schloendorff doctrine” regards a physician, even if employed by a hospital, as an independent contractorbecause of the skill he exercises and the lack of control exerted over his work. Under this doctrine, hospitals are exempt from the application of the respondeat superiorprinciple for fault or negligence committed by physicians in the discharge of their profession. However, the efficacy of the foregoing doctrine has weakened with the significant developments in medical care. Courts came to realize that modern hospitals are increasingly taking active role in supplying and regulating medical care to patients. No longer were a hospital’s functions limited to furnishing room, food, facilities for treatment and operation, and attendants for its patients. Thus, in Bing v. Thunig, the New York Court of Appeals deviated from the Schloendorff doctrine, noting that modern hospitals actually do far more than provide facilities for treatment. Rather, they regularly 25

26

27

25

Kitto v. Gilbert, 39 Colo App 374, 570 P. 2d 544 (1977).

26

211 N.Y. 125, 105 N.E. 92, 52 L.R.A., N.S., 505 (1914). The court

inSchloendorff opined that a hospital does not act through physicians but merely procures them to act on their own initiative and responsibility. For subsequent application of the doctrine, see for instance, Hendrickson v. Hodkin, 250 App. Div 649, 294 NYS 982, revd on other grounds, 276 NY 252, 11 NE 2d 899 (1937); Necolayff v. Genesee Hosp., 270 App. Div. 648, 61 NYS 2d 832, affd 296 NY 936, 73 NE2d 117 (1946); Davie v. Lenox Hill Hosp., Inc., 81 NYS 2d 583 (1948); Roth v. Beth El Hosp., Inc., 279 App. Div 917, 110 NYS 2d 583 (1952); Rufino v. US, 126 F. Supp. 132 (1954);Mrachek v. Sunshine Biscuit, Inc., 308 NY 116, 123 N.E. 2d 801 (1954). 27

2 NY 2d 656, 163 NYS 2d 3, 143 N.E. 2d 3 (1957).

499

VOL. 513, JANUARY 31, 2007 Professional Services, Inc. vs. Agana

499

employ, on a salaried basis, a large staff of physicians, interns, nurses, administrative and manual workers. They charge patients for medical care and treatment, even collecting for such services through legal action, if necessary. The court then concluded that there is no reason to exempt hospitals from the universal rule of respondeat superior. In our shores, the nature of the relationship between the hospital and the physicians is rendered inconsequential in view of our categorical pronouncement in Ramos v. Court of Appeals that for purposes of apportioning responsibility in medical negligence cases, an employer-employee relationship in 28

_______________

24

Fridena v. Evans, 127 Ariz. 516, 522 P. 2d 463 (1980).

effect exists between hospitals and their attending and visiting physicians. This Court held:

privilege of being able to maintain a clinic in the hospital, and/or

“We now discuss the responsibility of the hospital in this particular

for the privilege of admitting patients into the hospital. In

incident. The unique practice (among private hospitals) of filling up

addition to these, the physician’s performance as a specialist is generally

specialist staff with attending and visiting “consultants,” who are

evaluated by a peer review committee on the basis of mortality and

allegedly not hospital employees, presents problems in apportioning

morbidity statistics, and feedback from patients, nurses, interns and

responsibility for negligence in medical malpractice cases. However, the

residents. A consultant remiss in his duties, or a consultant who

difficulty is more apparent than real.

regularly falls short of the minimum standards acceptable to the

In the first place, hospitals exercise significant control in the hiring and firing of consultants and in the conduct of their work

Professional Services, Inc. vs. Agana

hospital or its peer review committee, is normally politely terminated.

within the hospital premises. Doctors who apply for ‘consultant’

In other words, private hospitals, hire, fire and exercise real

slots, visiting or attending, are required to submit proof of

control over their attending and visiting ‘consultant’ staff. While

completion

qualifications,

‘consultants’ are not, technically employees, x x x, the control

generally, evidence of accreditation by the appropriate board

exercised, the hiring, and the right to terminate consultants all

(diplomate), evidence of fellowship in most cases, and references.

fulfill

These requirements are carefully scrutinized by members of the

relationship, with the exception of the payment of wages. In

hospital administration or by a review committee set up by the

assessing whether such a relationship in fact exists, the control test is

hospital who either accept or reject the application. x x x.

determining. Accordingly, on the basis of the foregoing, we rule that for

of

residency,

their

educational

the

important

hallmarks

of

an

employer-employee

After a physician is accepted, either as a visiting or attending

the purpose of allocating responsibility in medical negligence

consultant, he is normally required to attend clinicopathological

cases, an employeremployee relationship in effect exists between

conferences, conduct bedside rounds for clerks, interns and

hospitals and their attending and visiting physicians.”

residents, moderate grand rounds and patient audits and

But the Ramos pronouncement is not our only basis in sustaining PSI’s liability. Its liability is also anchored upon the agency principle of apparent authority or agency by estoppel and the doctrine of corporate negligence which have gained acceptance in the determination of a hospital’s liability for negligent acts of health professionals. The present case serves as a

perform other tasks and responsibilities, for the _______________

28

Supra at footnote 13.

500

500

SUPREME COURT REPORTS ANNOTATED

perfect platform to test the applicability of these doctrines, thus, enriching our jurisprudence. Apparent authority, or what is sometimes referred to as the “holding out” theory, or doctrine of ostensible agency or agency by estoppel, has its origin from the law of agency. It

business usages and the nature of the particular business, is justified in

_______________

_______________

presuming that such agent has authority to perform the particular act in question.

31

The applicability of apparent authority in the field of hospital liability was upheld long time ago in Irving v. Doctor Hos-

29

Black’s Law Dictionary (6th Ed. 1990) 1100. The terms “ostensible agency,”

579 P2d 970 (1978). Agency by estoppel is defined as “one created by operation

“agency by estoppel,” “apparent authority,” and “holding out” tend to be used

of law and established by proof of such acts of the principal as reasonably lead

interchangeably by the courts to refer to this theory of liability. See for

third persons to the conclusion of its existence. Arises where principal by

instance, Baker v. Werner, 654 P2d 263 (1982) andAdamski v. Tacoma Gen. Hosp.,

negligence in failing to supervise agent’s affairs, allows agent to exercise powers

20 Wash App. 98,

not granted to him, thus justifying others in believing the agent possesses

29

501

requisite authority.” Black’s, supra, p. 62. An ostensible agency is “an implied or

VOL. 513, JANUARY 31, 2007 Professional Services, Inc. vs. Agana

imposes liability, not as the result of the reality of a contractual relationship, but rather because of the actions of a principal or an employer in somehow misleading the public into believing that the relationship or the authority exists. The concept is essentially one of estoppel and has been explained in this manner: 30

“The principal is bound by the acts of his agent with the apparent authority which he knowingly permits the agent to assume, or which he holds the agent out to the public as possessing. The question in every case is whether the principal has by his voluntary act placed the agent in such a situation that a person of ordinary prudence, conversant with

501

presumptive agency which exists where one, either intentionally or from want of ordinary care, induces another to believe that a third person is his agent, though he never in fact, employed him. It is, strictly speaking, no agency at all, but is in reality based entirely upon estoppel.” Apparent authority refers to “the power to affect the legal relations of another person by transactions with third persons, professedly as agent for the other, arising from and in accordance with the other’s manifestations to such third persons.” Supra, p. 96. 30

Irving v. Doctors Hospital of Lake Worth, Inc., 415 So. 2d 55 (1982),

quoting Arthur v. St. Peters Hospital, 169 N.J. 575, 405 A. 2d 443 (1979). 31

Id., citing Hudson v. C., Loan Assn., Inc. v. Horowytz, 116 N.J.L. 605, 608,

186 A 437 (Sup. Ct. 1936).

502

502

SUPREME COURT REPORTS ANNOTATED Professional Services, Inc. vs. Agana

pital of Lake Worth, Inc. There, it was explicitly stated that “there does not appear to be any rational basis for excluding the concept of apparent authority from the field of hospital liability.” Thus, in cases where it can be shown that a hospital, by its actions, has held out a particular physician as its agent and/or employee and that a patient has accepted treatment from that physician in the reasonable belief that it is being rendered in behalf of the hospital, then the hospital will be liable for the physician’s negligence. Our jurisdiction recognizes the concept of an agency by implication or estoppel. Article 1869 of the Civil Code reads: 32

ART. 1869. Agency may be express, or implied from the acts of the

quality health care services. By accrediting Dr. Ampil and Dr. Fuentes and publicly advertising their qualifications, the hospital created the impression that they were its agents, authorized to perform medical or surgical services for its patients. As expected, these patients, Natividad being one of them, accepted the services on the reasonable belief that such were being rendered by the hospital or its employees, agents, or servants. The trial court correctly pointed out: _______________

32

Supra.

503

VOL. 513, JANUARY 31, 2007 Professional Services, Inc. vs. Agana

principal, from his silence or lack of action, or his failure to repudiate the agency, knowing that another person is acting on his behalf without authority.

In this case, PSI publicly displays in the lobby of the Medical City Hospital the names and specializations of the physicians associated or accredited by it, including those of Dr. Ampil and Dr. Fuentes. We concur with the Court of Appeals’ conclusion that it “is now estopped from passing all the blame to the physicians whose names it proudly paraded in the public directory leading the public to believe that it vouched for their skill and competence.” Indeed, PSI’s act is tantamount to holding out to the public that Medical City Hospital, through its accredited physicians, offers

503

“x x x regardless of the education and status in life of the patient, he ought not be burdened with the defense of absence of employer-employee relationship between the hospital and the independent

physician

whose

name

and

competence

are

certainly certified to the general public by the hospital’s act of listing him and his specialty in its lobby directory, as in the case herein. The high costs of today’s medical and health care should at least exact on the hospital greater, if not broader, legal responsibility for the conduct of treatment and surgery within its facility by its accredited physician or surgeon, regardless of whether he is independent or employed.”

33

The wisdom of the foregoing ratiocination is easy to discern. Corporate entities, like PSI, are capable of

acting only through other individuals, such as physicians. If these accredited physicians do their job well, the hospital succeeds in its mission of offering quality medical services and thus profits financially. Logically, where negligence mars the quality of its services, the hospital should not be allowed to escape liability for the acts of its ostensible agents. We now proceed to the doctrine of corporate negligence or corporate responsibility. One allegation in the complaint in Civil Case No. Q43332 for negligence and malpractice is that PSI as owner, operator and manager of Medical City Hospital, “did not perform the necessary supervision nor exercise diligent efforts in the supervision of Drs. Ampil and Fuentes and its nursing staff, resident doctors, and medical interns who assisted Drs. Ampil and Fuentes in the performance of their duties as surgeons.” Premised on the doctrine of corporate negligence, the trial court held that PSI is directly liable for such breach of duty. We agree with the trial court. 34

_______________

33

RTC Decision, p. 9, Rollo of G.R. No. 126467, p. 127.

34

RTC Decision, p. 2, Rollo of G.R. No. 126467, p. 120.

504

504

Recent years have seen the doctrine of corporate negligence as the judicial answer to the problem of allocating hospital’s liability for the negligent acts of health practitioners, absent facts to support the application ofrespondeat superior or apparent authority. Its formulation proceeds from the judiciary’s acknowledgment that in these modern times, the duty of providing quality medical service is no longer the sole prerogative and responsibility of the physician. The modern hospitals have changed structure. Hospitals now tend to organize a highly professional medical staff whose competence and performance need to be monitored by the hospitals commensurate with their inherent responsibility to provide quality medical care. The doctrine has its genesis in Darling v. Charleston Community Hospital. There, the Supreme Court of Illinois held that “the jury could have found a hospital negligent, inter alia, in failing to have a sufficient number of trained nurses attending the patient; failing to require a consultation with or examination by members of the hospital staff; and failing to review the treatment rendered to the patient.” On the basis of Darling, other jurisdictions held that a hospital’s corporate negligence extends to permitting a physician known to be incompetent to practice at the hospital. With the passage of time, more duties were expected from hospitals, among them: (1) the use of 35

36

37

SUPREME COURT REPORTS ANNOTATED Professional Services, Inc. vs. Agana

reasonable care in the maintenance of safe and adequate facilities and equipment; (2) the selection and retention of competent physicians; (3) the overseeing or supervision of all persons who practice medicine within its walls; and (4) the formulation, adoption and enforcement of adequate rules

and administered by the physicians practicing in its premises. In the present case, it was duly established that PSI operates the Medical City Hospital for the purpose and under the concept of providing comprehensive medical services to the public. Accordingly, it has the duty to exercise reasonable care to protect from harm all patients admitted into its facility for medical treatment.Unfortunately, PSI failed to perform such duty. The findings of the trial court are convincing, thus:

_______________

35

Purcell v. Zimbelman, 18 Ariz. App. 75, 500 P2d 335 (1972).

36

Supra at footnote 1.

37

Corleto v. Hospital, 138 N.J. Super. 302, 350 A. 2d 534 (Super. Ct. Law

x x x PSI’s liability is traceable to its failure to conduct an

Div.1975); Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d 335 (1972); Hospital

investigation of the matter reported in the nota bene of the count

Authority v. Joiner, 229 Ga. 140,189 S.E. 2d 412 (1972).

nurse. Such failure established PSI’s part in the dark conspiracy

505

VOL. 513, JANUARY 31, 2007 Professional Services, Inc. vs. Agana

and policies that ensure quality care for its patients. Thus, in Tucson Medical Center, Inc. v. Misevich, it was held that a hospital, following the doctrine of corporate responsibility, has the duty to see that it meets the standards of responsibilities for the care of patients. Such duty includes the proper supervision of the members of its medical staff. And in Bost v. Riley, the court concluded that a patient who enters a hospital does so with the reasonable expectation that it will attempt to cure him. The hospital accordingly has the duty to make a reasonable effort to monitor and oversee the treatment prescribed 38

39

505

of

silence

and

concealment

about

the

gauzes. Ethical

considerations, if not also legal, dictated the holding of an immediate inquiry into the events, if not for the benefit of the patient to whom the duty is primarily owed, then in the interest of arriving at the truth. The Court cannot accept that the medical and the healing professions, through their members like defendant surgeons, and their institutions like PSI’s hospital facility, can callously turn their backs on and disregard even a mere probability of mistake or negligence by refusing or failing to investigate a report of such seriousness as the one in Natividad’s case.”

40

_______________

38

Welsh v. Bulger, 548 Pa. 504, 698 A.2d 581 (1997).

39

115 Ariz. 34, 545 P2d 958 (1976).

40

262 S.E. 2d 391, cert denied 300 NC 194, 269 S.E. 2d 621 (1980).

506

506

SUPREME COURT REPORTS ANNOTATED Professional Services, Inc. vs. Agana

It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad with the assistance of the Medical City Hospital’s staff, composed of resident doctors, nurses, and interns. As such, it is reasonable to conclude that PSI, as the operator of the hospital, has actual or constructiveknowledge of the procedures carried out, particularly the report of the attending nurses that the two pieces of gauze were missing. In Fridena v. Evans, it was held that a corporation is bound by the knowledge acquired by or notice given to its agents or officers within the scope of their authority and in reference to a matter to which their authority extends. This means that the knowledge of any of the staff of Medical City Hospital constitutes knowledge of PSI. Now, the failure of PSI, despite the attending nurses’ report, to investigate and inform Natividad regarding the missing gauzes amounts to callous negligence. Not only did PSI breach its duties to oversee or supervise all persons who practice medicine within its walls, it also failed to take an active step in fixing the negligence committed. This renders PSI, not only vicariously liable for the negligence of Dr. Ampil under Article 2180 of the Civil Code, but alsodirectly liable for its own negligence 41

under Article 2176. In Fridena, the Supreme Court of Arizona held: “x x x In recent years, however, the duty of care owed to the patient by the hospital has expanded. The emerging trend is to hold the hospital responsible where the hospital has failed to monitor and review medical services being provided within its walls. See Kahn Hospital Malpractice Prevention, 27 De Paul Rev. 23 (1977). Among the cases indicative of the ‘emerging trend’ is Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d 335 (1972). In Purcell, the hospital argued that it could not be held liable for the malpractice of a medical practitioner because he was an independent contractor within the hospital. The Court of Appeals pointed out that the hospital had created a professional staff whose competence _______________

41

127 Ariz. 516, 622 P. 2d 463 (1980).

507

VOL. 513, JANUARY 31, 2007 Professional Services, Inc. vs. Agana and performance was to be monitored and reviewed by the governing body of the hospital, and the court held that a hospital would be negligent where it had knowledge or reason to believe that a doctor using the facilities was employing a method of treatment or care which fell below the recognized standard of care. Subsequent to the Purcell decision, the Arizona Court of Appeals held that a hospital has certain inherent responsibilities regarding the quality of medical care furnished to patients

507

within its walls and it must meet the standards of responsibility commensurate with this undertaking. Beeck v. Tucson General

must possess that reasonable degree of learning, skill and experience required by 508

Hospital, 18 Ariz. App. 165, 500 P. 2d 1153 (1972). This court has confirmed the rulings of the Court of Appeals that a hospital has the duty

508

of supervising the competence of the doctors on its staff. x x x. xxx

xxx

In the amended complaint, the plaintiffs did plead that the operation was performed at the hospital with its knowledge, aid, and assistance, and that the negligence of the defendants was the proximate cause of the patient’s injuries. We

find

that

such

general

allegations

of

negligence, along with the evidence produced at the trial of this case, are sufficient to support the hospital’s liability based on the theory of negligent supervision.”

Anent the corollary issue of whether PSI is solidarily liable with Dr. Ampil for damages, let it be emphasized that PSI, apart from a general denial of its responsibility, failed to adduce evidence showing that it exercised the diligence of a good father of a family in the accreditation and supervision of the latter. In neglecting to offer such proof, PSI failed to discharge its burden under the last paragraph of Article 2180 cited earlier, and, therefore, must be adjudged solidarily liable with Dr. Ampil. Moreover, as we have discussed, PSI is also directly liable to the Aganas. One final word. Once a physician undertakes the treatment and care of a patient, the law imposes on him certain obligations. In order to escape liability, he

SUPREME COURT REPORTS ANNOTATED Professional Services, Inc. vs. Agana

his profession. At the same time, he must apply reasonable care and diligence in the exercise of his skill and the application of his knowledge, and exert his best judgment. WHEREFORE, we DENY all the petitions and AFFIRM the challenged Decision of the Court of Appeals in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198. Costs against petitioners PSI and Dr. Miguel Ampil. SO ORDERED. Puno (C.J., Chairperson), Corona and Azcuna, JJ., concur. Garcia, J., No part. Petitions denied, challenged CA decision in CA-G.R. No. CV No. 42062 and CA-G.R. SP No. 32198 affirmed. Note.—Under the Captain-of-the-Ship Doctrine, a surgeon is likened to a captain of the ship in that it is his duty to control everything going on in the operating room. (Ramos vs. Court of Appeals, 380 SCRA 467 [2002]) ——o0o——