SECOND DIVISION Factual Antecedents

The common factual antecedents are briefly summarized

[G.R. No. 171127. March 11, 2015.] below.
On April 22, 1988, at about 11:30 in the morning, Mrs.
NOEL CASUMPANG, RUBY SANGA-MIRANDA Jesusa Cortejo brought her 11-year old son, Edmer Cortejo
and SAN JUAN DE DIOS (Edmer), to the Emergency Room of the San Juan de Dios
HOSPITAL, petitioners, vs. NELSON Hospital (SJDH) because of difficulty in breathing, chest pain,
CORTEJO, respondent. stomach pain, and fever. 4
Dr. Ramoncito Livelo (Dr. Livelo) initially attended to and
[G.R. No. 171217. March 11, 2015.] examined Edmer. In her testimony, Mrs. Cortejo narrated that in
the morning of April 20, 1988, Edmer had developed a slight fever
DRA. RUBY SANGA- that lasted for one day; a few hours upon discovery, she brought
MIRANDA, petitioner, vs. NELSON Edmer to their family doctor; and two hours after administering
CORTEJO, respondent. medications, Edmer's fever had subsided. 5
After taking Edmer's medical history, Dr. Livelo took his
[G.R. No. 171228. March 11, 2015.] vital signs, body temperature, and blood pressure. 6 Based on
these initial examinations and the chest x-ray test that followed,
Dr. Livelo diagnosed Edmer with "bronchopneumonia." 7 Edmer's
SAN JUAN DE DIOS
blood was also taken for testing, typing, and for purposes of
HOSPITAL, petitioner, vs. NELSON
administering antibiotics. Afterwards, Dr. Livelo gave Edmer an
CORTEJO, respondent.
antibiotic medication to lessen his fever and to loosen his phlegm.
Mrs. Cortejo did not know any doctor at SJDH. She used
DECISION her Fortune Care card and was referred to an accredited Fortune
Care coordinator, who was then out of town. She was thereafter
assigned to Dr. Noel Casumpang (Dr. Casumpang), a pediatrician
BRION, J  p: also accredited with Fortune Care. 8
We resolve the three (3) consolidated petitions for review At 5:30 in the afternoon of the same day, Dr. Casumpang
on certiorari 1 involving medical negligence, commonly assailing for the first time examined Edmer in his room. Using only a
the October 29, 2004 decision 2 and the January 12, 2006 stethoscope, he confirmed the initial diagnosis of
resolution 3 of the Court of Appeals (CA) in CA-G.R. CV No. "Bronchopneumonia." 9
56400. This CA decision affirmed en toto the ruling of the
At that moment, Mrs. Cortejo recalled entertaining doubts
Regional Trial Court (RTC), Branch 134, Makati City.
on the doctor's diagnosis. She immediately advised Dr.
The RTC awarded Nelson Cortejo (respondent) damages Casumpang that Edmer had a high fever, and had no colds or
in the total amount of P595,000.00, for the wrongful death of his cough 10 but Dr. Casumpang merely told her that her son's "blood
son allegedly due to the medical negligence of the petitioning pressure is just being active," 11 and remarked that "that's the
doctors and the hospital. usual bronchopneumonia, no colds, no phlegm." 12

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 Dr. Casumpang next visited and examined Edmer at 9:00 afflicted with dengue, she inserted a plastic tube in his nose,
in the morning the following day. 13 Still suspicious about his drained the liquid from his stomach with ice cold normal saline
son's illness, Mrs. Cortejo again called Dr. Casumpang's attention solution, and gave an instruction not to pull out the tube, or give
and stated that Edmer had a fever, throat irritation, as well as the patient any oral medication.
chest and stomach pain. Mrs. Cortejo also alerted Dr. Casumpang
Dr. Miranda thereafter conducted a tourniquet test, which
about the traces of blood in Edmer's sputum. Despite these pieces
turned out to be negative. 20 She likewise ordered the monitoring
of information, however, Dr. Casumpang simply nodded, inquired
of the patient's blood pressure and some blood tests. Edmer's
if Edmer has an asthma, and reassured Mrs. Cortejo that Edmer's
blood pressure was later found to be normal. 21
illness is bronchopneumonia. 14
At 4:40 in the afternoon, Dr. Miranda called up Dr.
At around 11:30 in the morning of April 23, 1988, Edmer
Casumpang at his clinic and told him about Edmer's
vomited "phlegm with blood streak" 15 prompting the respondent
condition. 22 Upon being informed, Dr. Casumpang ordered
(Edmer's father) to request for a doctor at the nurses' station. 16
several procedures done including: hematocrit, hemoglobin, blood
Forty-five minutes later, Dr. Ruby Sanga-Miranda (Dr. typing, blood transfusion and tourniquet tests.
Miranda), one of the resident physicians of SJDH, arrived. She
The blood test results came at about 6:00 in the evening.
claimed that although aware that Edmer had vomited "phlegm with
blood streak," she failed to examine the blood specimen because Dr. Miranda advised Edmer's parents that the blood test
the respondent washed it away. She then advised the respondent results showed that Edmer was suffering from "Dengue
to preserve the specimen for examination. Hemorrhagic Fever." One hour later, Dr. Casumpang arrived at
Edmer's room and he recommended his transfer to the Intensive
Thereafter, Dr. Miranda conducted a physical check-up
Care Unit (ICU), to which the respondent consented. Since the
covering Edmer's head, eyes, nose, throat, lungs, skin and
ICU was then full, Dr. Casumpang suggested to the respondent
abdomen; and found that Edmer had a low-grade non-continuing
that they hire a private nurse. The respondent, however, insisted
fever, and rashes that were not typical of dengue fever. 17 Her
on transferring his son to Makati Medical Center.
medical findings state: aScITE
After the respondent had signed the waiver, Dr.
the patient's rapid breathing and then the
Casumpang, for the last time, checked Edmer's condition, found
lung showed sibilant and the patient's nose is
that his blood pressure was stable, and noted that he was
flaring which is a sign that the patient is in
"comfortable." The respondent requested for an ambulance but he
respiratory distress; the abdomen has negative
was informed that the driver was nowhere to be found. This
finding; the patient has low grade fever and not
prompted him to hire a private ambulance that cost him
continuing; and the rashes in the patient's skin
P600.00. 23 DETACa
were not "Herman's Rash" and not typical of
dengue fever. 18 At 12:00 midnight, Edmer, accompanied by his parents
and by Dr. Casumpang, was transferred to Makati Medical Center.
At 3:00 in the afternoon, Edmer once again vomited blood.
Upon seeing Dr. Miranda, the respondent showed her Edmer's Dr. Casumpang immediately gave the attending physician
blood specimen, and reported that Edmer had complained of the patient's clinical history and laboratory exam results. Upon
severe stomach pain and difficulty in moving his right leg. 19 examination, the attending physician diagnosed "Dengue Fever
Stage IV" that was already in its irreversible stage.
Dr. Miranda then examined Edmer's "sputum with blood"
and noted that he was bleeding. Suspecting that he could be

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 Edmer died at 4:00 in the morning of April 24, 1988. 24 His and competence as a medical practitioner; and second, Dr.
Death Certificate indicated the cause of death as "Hypovolemic Miranda, as resident physician, is an employee of SJDH because
Shock/hemorrhagic shock;" "Dengue Hemorrhagic Fever Stage like Dr. Casumpang, the hospital, through its screening
IV." committee, scrutinized and determined her qualifications, fitness,
and competence before engaging her services; the hospital also
Believing that Edmer's death was caused by the negligent
exercised control over her work.
and erroneous diagnosis of his doctors, the respondent instituted
an action for damages against SJDH, and its attending physicians: The dispositive portion of the decision reads:
Dr. Casumpang and Dr. Miranda (collectively referred to as the
WHEREFORE, judgment is hereby
"petitioners") before the RTC of Makati City.
rendered in favor of the plaintiff and against the
The Ruling of the Regional Trial Court defendants, ordering the latter to pay solidarily and
severally plaintiff the following:
In a decision 25 dated May 30, 1997, the RTC ruled in
favor of the respondent, and awarded actual and moral damages, (1) Moral damages in the amount of
plus attorney's fees and costs. P500,000.00;
In ruling that the petitioning doctors were negligent, the
RTC found untenable the petitioning doctors' contention that (2) Costs of burial and funeral in the amount
Edmer's initial symptoms did not indicate dengue fever. It faulted of P45,000.00;
them for heavily relying on the chest x-ray result and for not
considering the other manifestations that Edmer's parents had (3) Attorney's fees of P50,000.00; and
relayed. It held that in diagnosing and treating an illness, the
physician's conduct should be judged not only by what he/she saw (4) Cost of this suit.
and knew, but also by what he/she could have reasonably seen
and known. It also observed that based on Edmer's signs and SO ORDERED.
symptoms, his medical history and physical examination, and The petitioners appealed the decision to the CA. aDSIHc
also the information that the petitioning doctors gathered from his
family members, dengue fever was a reasonably foreseeable The Ruling of the Court of Appeals
illness; yet, the petitioning doctors failed to take a second look, In its decision dated October 29, 2004, the CA affirmed en
much less, consider these indicators of dengue. toto the RTC's ruling, finding that SJDH and its attending
The trial court also found that aside from their self-serving physicians failed to exercise the minimum medical care, attention,
testimonies, the petitioning doctors did not present other evidence and treatment expected of an ordinary doctor under like
to prove that they exercised the proper medical attention in circumstances.
diagnosing and treating the patient, leading it to conclude that they The CA found the petitioning doctors' failure to read even
were guilty of negligence. the most basic signs of "dengue fever" expected of an ordinary
The RTC also held SJDH solidarily liable with the doctor as medical negligence. The CA also considered the
petitioning doctors for damages based on the following findings of petitioning doctors' testimonies as self-serving, noting that they
facts: first, Dr. Casumpang, as consultant, is an ostensible agent presented no other evidence to prove that they exercised due
of SJDH because before the hospital engaged his medical diligence in diagnosing Edmer's illness.
services, it scrutinized and determined his fitness, qualifications,

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 The CA likewise found Dr. Rodolfo Jaudian's (Dr. Jaudian) training, skills, and experience as a specialist in dengue fever
testimony admissible. It gave credence to his opinion 26 that: (1) cases.
given the exhibited symptoms of the patient, dengue fever should
II. Dr. Miranda's Position (G.R. No. 171217)
definitely be considered, and bronchopneumonia could be
reasonably ruled out; and (2) dengue fever could have been In her petition, Dr. Miranda faults the CA for holding her
detected earlier than 7:30 in the evening of April 23, 1988 responsible for Edmer's wrong diagnosis, stressing that the
because the symptoms were already evident; and agreed with the function of making the diagnosis and undertaking the medical
RTC that the petitioning doctors should not have solely relied on treatment devolved upon Dr. Casumpang, the doctor assigned to
the chest-x-ray result, as it was not conclusive. Edmer, and who confirmed "bronchopneumonia."
On SJDH's solidary liability, the CA ruled that the hospital's Dr. Miranda also alleged that she exercised prudence in
liability is based on Article 2180 of the Civil Code. The CA opined performing her duties as a physician, underscoring that it was her
that the control which the hospital exercises over its consultants, professional intervention that led to the correct diagnosis of
the hospital's power to hire and terminate their services, all fulfill "Dengue Hemorrhagic Fever." Furthermore, Edmer's Complete
the employer-employee relationship requirement under Article Blood Count (CBC) showed leukopenia and an increase in
2180. balance as shown by the differential count, demonstrating that
Edmer's infection, more or less, is of bacterial and not viral in
Lastly, the CA held that SJDH failed to adduce evidence
nature.
showing that it exercised the diligence of a good father of a family
in the hiring and the supervision of its physicians. Dr. Miranda as well argued that there is no causal relation
between the alleged erroneous diagnosis and medication for
The petitioners separately moved to reconsider the CA
"Bronchopneumonia," and Edmer's death due to "Dengue
decision, but the CA denied their motion in its resolution of
Hemorrhagic Fever."
January 12, 2006; hence, the present consolidated petitions
pursuant to Rule 45 of the Rules of Court. ATICcS Lastly, she claimed that Dr. Jaudian is not a qualified
expert witness since he never presented any evidence of formal
The Petitions
residency training and fellowship status in Pediatrics.
I. Dr. Casumpang's Position (G.R. No. 171127)
III. SJDH's Position (G.R. No. 171228)
Dr. Casumpang contends that he gave his patient medical
SJDH, on the other hand, disclaims liability by asserting
treatment and care to the best of his abilities, and within the
that Dr. Casumpang and Dr. Miranda are mere independent
proper standard of care required from physicians under similar
contractors and "consultants" (not employees) of the hospital.
circumstances. He claims that his initial diagnosis of
SJDH alleges that since it did not exercise control or supervision
bronchopneumonia was supported by the chest x-ray result.
over the consultants' exercise of medical profession, there is no
Dr. Casumpang also contends that dengue fever occurs employer-employee relationship between them, and consequently,
only after several days of confinement. He alleged that when he Article 2180 of the Civil Code does not apply.
had suspected that Edmer might be suffering from dengue fever,
SJDH likewise anchored the absence of employer-
he immediately attended and treated him.
employee relationship on the following circumstances: (1) SJDH
Dr. Casumpang likewise raised serious doubts on Dr. does not hire consultants; it only grants them privileges to admit
Jaudian's credibility, arguing that the CA erred in appreciating his patients in the hospital through accreditation; (2) SJDH does not
testimony as an expert witness since he lacked the necessary pay the consultants wages similar to an ordinary employee; (3) the

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 consultants earn their own professional fees directly from their The Case for the Respondent
patients; SJDH does not fire or terminate their services; and (4)
In his comment, the respondent submits that the issues the
SJDH does not control or interfere with the manner and the means
petitioners raised are mainly factual in nature, which a petition for
the consultants use in the treatment of their patients. It merely
review on certiorari under Rule 45 of the Rules of Court does not
provides them with adequate space in exchange for rental
allow. cSEDTC
payment.
In any case, he contends that the petitioning doctors were
Furthermore, SJDH claims that the CA erroneously applied
negligent in conducting their medical examination and diagnosis
the control test when it treated the hospital's practice of
based on the following: (1) the petitioning doctors failed to timely
accrediting consultants as an exercise of control. It explained that
diagnose Edmer's correct illness due to their non-observance of
the control contemplated by law is that which the employer
the proper and acceptable standard of medical examination; (2)
exercises over the: (i) end result; and the (ii) manner and means
the petitioning doctors' medical examination was not
to be used to reach this end, and not any kind of control, however
comprehensive, as they were always in a rush; and (3) the
significant, in accrediting the consultants.
petitioning doctors employed a guessing game in diagnosing
SJDH moreover contends that even if the petitioning bronchopneumonia.
doctors are considered employees and not merely consultants of
The respondent also alleges that there is a causal
the hospital, SJDH cannot still be held solidarily liable under
connection between the petitioning doctors' negligence and
Article 2180 of the Civil Code because it observed the diligence of
Edmer's untimely death, warranting the claim for damages.
a good father of a family in their selection and supervision as
shown by the following: (1) the adequate measures that the The respondent, too, asserted that SJDH is also negligent
hospital undertakes to ascertain the petitioning doctors' because it was not equipped with proper paging system, has no
qualifications and medical competence; and (2) the documentary bronchoscope, and its doctors are not proportionate to the number
evidence that the petitioning doctors presented to prove their of its patients. He also pointed out that out of the seven resident
competence in the field of pediatrics. 27 physicians in the hospital, only two resident physicians were doing
rounds at the time of his son's confinement.
SJDH likewise faults the CA for ruling that the petitioning
doctors are its agents, claiming that this theory, aside from being The Issues
inconsistent with the CA's finding of employment relationship, is The case presents to us the following issues:
unfounded because: first, the petitioning doctors are independent
contractors, not agents of SJDH; and second, as a medical 1. Whether or not the petitioning doctors had committed
institution, SJDH cannot practice medicine, much more, extend its "inexcusable lack of precaution" in diagnosing and
personality to physicians to practice medicine on its behalf. in treating the patient;
Lastly, SJDH maintains that the petitioning doctors arrived 2. Whether or not the petitioner hospital is solidarily liable
at an intelligently deduced and correct diagnosis. It claimed that with the petitioning doctors;
based on Edmer's signs and symptoms at the time of admission 3. Whether or not there is a causal connection between the
(i.e., one day fever, 28 bacterial infection, 29 and lack of petitioners' negligent act/omission and the patient's
hemorrhagic manifestations 30), there was no reasonable resulting death; and
indication yet that he was suffering from dengue fever, and
accordingly, their failure to diagnose dengue fever, does not 4. Whether or not the lower courts erred in considering Dr.
constitute negligence on their part. Rodolfo Tabangcora Jaudian as an expert witness.

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 Our Ruling standards demanded by his profession, or deviates from this
standard, and causes injury to the patient.
We find the petition partly meritorious.
To successfully pursue a medical malpractice suit, the
A Petition for Review on Certiorari
plaintiff (in this case, the deceased patient's heir) must prove that
under Rule 45 of the Rules of Court
the doctor either failed to do what a reasonably prudent doctor
is Limited to Questions of Law.
would have done, or did what a reasonably prudent doctor would
The settled rule is that the Court's jurisdiction in a petition not have done; and the act or omission had caused injury to the
for review on certiorari under Rule 45 of the Rules of Court is patient. 34 The patient's heir/s bears the burden of proving his/her
limited only to the review of pure questions of law. It is not the cause of action.
Court's function to inquire on the veracity of the appellate court's
The Elements of a Medical Malpractice Suit
factual findings and conclusions; this Court is not a trier of
facts. 31 The elements of medical negligence are: (1) duty; (2)
breach; (3) injury; and (4) proximate causation.
A question of law arises when there is doubt as to what the
law is on a certain state of facts, while there is a question of fact Duty refers to the standard of behavior that imposes
when the doubt arises as to the truth or falsity of the alleged restrictions on one's conduct. 35 It requires proof of professional
facts. 32 relationship between the physician and the patient. Without the
professional relationship, a physician owes no duty to the patient,
These consolidated petitions before us involve mixed
and cannot therefore incur any liability.
questions of fact and law. As a rule, we do not resolve questions
of fact. However, in determining the legal question of whether the A physician-patient relationship is created when a patient
respondent is entitled to claim damages under Article 2176 of engages the services of a physician, 36 and the latter accepts or
the Civil Code for the petitioners' alleged medical malpractice, the agrees to provide care to the patient. 37 The establishment of this
determination of the factual issues — i.e., whether the petitioning relationship is consensual, 38 and the acceptance by the
doctors were grossly negligent in diagnosing the patient's illness, physician essential. The mere fact that an individual approaches a
whether there is causal relation between the petitioners' physician and seeks diagnosis, advice or treatment does not
act/omission and the patient's resulting death, and whether Dr. create the duty of care unless the physician agrees. 39
Jaudian is qualified as an expert witness — must necessarily be
The consent needed to create the relationship does not
resolved. We resolve these factual questions solely for the
always need to be express. 40 In the absence of an express
purpose of determining the legal issues raised. SDAaTC
agreement, a physician-patient relationship may be implied from
Medical Malpractice Suit as a the physician's affirmative action to diagnose and/or treat a
Specialized Area of Tort Law patient, or in his participation in such diagnosis and/or
treatment. 41 The usual illustration would be the case of a patient
The claim for damages is based on the petitioning doctors'
who goes to a hospital or a clinic, and is examined and treated by
negligence in diagnosing and treating the deceased Edmer, the
the doctor. In this case, we can infer, based on the established
child of the respondent. It is a medical malpractice suit, an
and customary practice in the medical community that a patient-
action available to victims to redress a wrong committed by
physician relationship exists.
medical professionals who caused bodily harm to, or the death of,
a patient. 33 As the term is used, the suit is brought whenever a Once a physician-patient relationship is established, the
medical practitioner or health care provider fails to meet the legal duty of care follows. The doctor accordingly becomes duty-
bound to use at least the same standard of care that a reasonably
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 competent doctor would use to treat a medical condition under patient relationship with the hospital's patients when she
similar circumstances. participated in the diagnosis and prescribed a course of treatment
for Edmer.
Breach of duty occurs when the doctor fails to comply with,
or improperly performs his duties under professional standards. The undisputed evidence shows that Dr. Miranda
This determination is both factual and legal, and is specific to each examined Edmer twice (at around 12:00 and 3:30 in the afternoon
individual case. 42 of April 23, 1988), and in both instances, she prescribed treatment
and participated in the diagnosis of Edmer's medical condition.
If the patient, as a result of the breach of duty, is injured in
Her affirmative acts amounted to her acceptance of the physician-
body or in health, actionable malpractice is committed, entitling
patient relationship, and incidentally, the legal duty of care that
the patient to damages. 43
went with it.
To successfully claim damages, the patient must lastly
In Jarcia, Jr. v. People of the Philippines, 46 the Court
prove the causal relation between the negligence and the injury.
found the doctors who merely passed by and were requested to
This connection must be direct, natural, and should be unbroken
attend to the patient, liable for medical malpractice. It held that a
by any intervening efficient causes. In other words, the
physician-patient relationship was established when they
negligence must be the proximate cause of the injury. 44 The
examined the patient, and later assured the mother that
injury or damage is proximately caused by the physician's
everything was fine.
negligence when it appears, based on the evidence and the
expert testimony, that the negligence played an integral part in In the US case of Mead v. Legacy Health System, 47 the
causing the injury or damage, and that the injury or damage was Court also considered the rendering of an opinion in the course of
either a direct result, or a reasonably probable consequence of the the patient's care as the doctor's assent to the physician-patient
physician's negligence. 45 acEHCD relationship. It ruled that the relationship was formed because of
the doctor's affirmative action.
a. The Relationship between Dr. Casumpang and
Edmer Likewise, in Wax v. Johnson, 48 the court found that a
physician-patient relationship was formed between a physician
In the present case, the physician-patient relationship
who "contracts, agrees, undertakes, or otherwise assumes" the
between Dr. Casumpang and Edmer was created when the latter's
obligation to provide resident supervision at a teaching hospital,
parents sought the medical services of Dr. Casumpang, and the
and the patient with whom the doctor had no direct or indirect
latter knowingly accepted Edmer as a patient. Dr. Casumpang's
contract.
acceptance is implied from his affirmative examination, diagnosis
and treatment of Edmer. On the other hand, Edmer's parents, on Standard of Care and Breach of Duty
their son's behalf, manifested their consent by availing of the
A determination of whether or not the petitioning doctors
benefits of their health care plan, and by accepting the hospital's
met the required standard of care involves a question of mixed
assigned doctor without objections.
fact and law; it is factual as medical negligence cases are highly
b. The Relationship between Dr. Miranda and Edmer technical in nature, requiring the presentation of expert witnesses
to provide guidance to the court on matters clearly falling within
With respect to Dr. Miranda, her professional relationship
the domain of medical science, and legal, insofar as the Court,
with Edmer arose when she assumed the obligation to provide
after evaluating the expert testimonies, and guided by medical
resident supervision over the latter. As second year resident
literature, learned treatises, and its fund of common knowledge,
doctor tasked to do rounds and assist other physicians, Dr.
ultimately determines whether breach of duty took place.
Miranda is deemed to have agreed to the creation of physician-
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 Whether or not Dr. Casumpang and Dr. Miranda hence, was guilty of breach of duty. We do not find Dr.
committed a breach of duty is to be measured by the yardstick of Miranda liable for the reasons discussed below.
professional standards observed by the other members of the
Dr. Casumpang's Negligence
medical profession in good standing under similar
circumstances. 49 It is in this aspect of medical malpractice that a. Negligence in the Diagnosis
expert testimony is essential to establish not only the professional At the trial, Dr. Casumpang declared that a doctor's
standards observed in the medical community, but also that the impression regarding a patient's illness is 90% based on the
physician's conduct in the treatment of care falls below such physical examination, the information given by the patient or the
standard. 50 latter's parents, and the patient's medical history. 55 He testified
In the present case, expert testimony is crucial in that he did not consider either dengue fever or dengue
determining first, the standard medical examinations, tests, and hemorrhagic fever because the patient's history showed that
procedures that the attending physicians should have undertaken Edmer had low breath and voluntary submission, and that he was
in the diagnosis and treatment of dengue fever; and second, the up and about playing basketball. 56 He based his diagnosis of
dengue fever signs and symptoms that the attending physicians bronchopneumonia on the following observations: "difficulty in
should have noticed and considered. breathing, clearing run nostril, harsh breath sound, tight air, and
sivilant sound." 57
Both the RTC and the CA relied largely on Dr. Jaudian's
expert testimony on dengue diagnosis and management to It will be recalled that during Dr. Casumpang's first and
support their finding that the petitioning doctors were guilty of second visits to Edmer, he already had knowledge of Edmer's
breach of duty of care. SDHTEC laboratory test result (CBC), medical history, and symptoms
(i.e., fever, rashes, rapid breathing, chest and stomach pain,
Dr. Jaudian testified that Edmer's rapid breathing, chest
throat irritation, difficulty in breathing, and traces of blood in the
and stomach pain, fever, and the presence of blood in his saliva
sputum). However, these information did not lead Dr.
are classic symptoms of dengue fever. According to him, if the
Casumpang to the possibility that Edmer could be suffering
patient was admitted for chest pain, abdominal pain, and difficulty
from either dengue fever, or dengue hemorrhagic fever, as he
in breathing coupled with fever, dengue fever should definitely be
clung to his diagnosis of broncho pneumonia. This means that
considered; 51 if the patient spits coffee ground with the presence
given the symptoms exhibited, Dr. Casumpang already ruled out
of blood, and the patient's platelet count drops to 47,000, it
the possibility of other diseases like dengue.
becomes a clear case of dengue fever, and bronchopneumonia
can be reasonably ruled out. 52 In other words, it was lost on Dr. Casumpang that the
characteristic symptoms of dengue (as Dr. Jaudian testified)
Furthermore, the standard of care according to Dr. Jaudian
are: patient's rapid breathing; chest and stomach pain; fever; and
is to administer oxygen inhalation, analgesic, and fluid infusion or
the presence of blood in his saliva. All these manifestations were
dextrose. 53 If the patient had twice vomited fresh blood and
present and known to Dr. Casumpang at the time of his first and
thrombocytopenia has already occurred, the doctor should
second visits to Edmer. While he noted some of these symptoms
order blood transfusion, monitoring of the patient every 30
in confirming bronchopneumonia, he did not seem to have
minutes, hemostatic to stop bleeding, and oxygen if there is
considered the patient's other manifestations in ruling out dengue
difficulty in breathing. 54
fever or dengue hemorrhagic fever. 58 To our mind, Dr.
We find that Dr. Casumpang, as Edmer's attending Casumpang selectively appreciated some, and not all of the
physician, did not act according to these standards and, symptoms; worse, he casually ignored the pieces of information

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 that could have been material in detecting dengue fever. This is what is all about and he has throat
evident from the testimony of Mrs. Cortejo: irritation.
TSN, Mrs. Cortejo, November 27, 1990 Q: What did he tell you?
Q: Now, when Dr. Casumpang visited your son for A: He just nodded his head but he did not take
the first time at 5:30 p.m., what did he do, if the initiative of looking at the throat of my
any? son.
A: He examined my son by using stethoscope and Q: So what happened after that?
after that, he confirmed to me that my son
A: I also told Dr. Casumpang about his chest pain
was suffering from broncho
and also stomach pain.
pneumonia. AScHCD
Q: So what did Dr. Casumpang do after you have
Q: After he confirmed that your son was suffering
narrated all these complaints of your son?
broncho pneumonia, what did you say if
any? A: Nothing. He also noticed the rapid breathing of
my son and my son was almost moving
A: Again, I told Dr. Casumpang, how come it was
because of rapid breathing and he is
broncho pneumonia when my son has no
swaying in the bed.
cough or colds.
Q: Do you know what action was taken by Dr.
Q: What was the answer of Dr. Casumpang to
Casumpang when you told him that your
your statement?
son is experiencing a rapid breathing?
xxx xxx xxx
A: No action. He just asked me if my son has an
A: And then, Dr. Casumpang answered "THAT'S asthma but I said none.
THE USUAL BRONCHO PNEUMONIA, NO
Q: So how long did Dr. Casumpang stay and
COLDS, NO PHLEGM."
attended your son on April 23?
Q: How long did Dr. Casumpang stay in your son's
A: More or less two (2) minutes then I followed
room?
him up to the door and I repeated about
A: He stayed for a minute or 2. the fever of my son.
xxx xxx xxx Q: What did he tell you, if any, regarding that
information you gave him that your son
Q: When Dr. Casumpang arrived at 9:00 o'clock a.m.
had a fever?
on April 23, what did you tell him, if any?
A: He said, that is broncho pneumonia, It's only
xxx xxx xxx
being active now. [Emphasis supplied]
A: I told Dr. Casumpang. . . After examining my
We also find it strange why Dr. Casumpang did not even
son using stethoscope and nothing more, I
bother to check Edmer's throat despite knowing that as early as
told Dr. Casumpang about the traces of
9:00 in the morning of April 23, 1988, Edmer had blood streaks in
blood in my son's sputum and I told him
his sputum. Neither did Dr. Casumpang order confirmatory tests to
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 confirm the source of bleeding. The Physician's Progress The Court also ruled that reasonable prudence would have
Notes 59 stated: "Blood streaks on phlegm can be due to shown that diabetes and its complications were foreseeable harm.
bronchial irritation or congestion," which clearly showed that Dr. However, the petitioner doctors failed to take this into
Casumpang merely assumed, without confirmatory physical consideration and proceeded with the D&C operation. Thus, the
examination, that bronchopneumonia caused the Court ruled that they failed to comply with their duty to observe the
bleeding. AcICHD standard of care to be given to hyperglycemic/diabetic patients.
Dr. Jaudian likewise opined that Dr. Casumpang's medical Similarly, in Jarcia, 64 involving the negligence of the
examination was not comprehensive enough to reasonably lead to doctors in failing to exercise reasonable prudence in ascertaining
a correct diagnosis. 60 Dr. Casumpang only used a stethoscope the extent of the patient's injuries, this Court declared that: caITAC
in coming up with the diagnosis that Edmer was suffering from
In failing to perform an extensive
bronchopneumonia; he never confirmed this finding with the use
medical examination to determine the extent of
of a bronchoscope. Furthermore, Dr. Casumpang based his
Roy, Jr.'s injuries, Dr. Jarcia and Dr. Bastan
diagnosis largely on the chest x-ray result that is generally
were remiss of their duties as members of the
inconclusive. 61
medical profession. Assuming for the sake of
Significantly, it was only at around 5:00 in the afternoon of argument that they did not have the capacity to
April 23, 1988 (after Edmer's third episode of bleeding) that Dr. make such thorough evaluation at that stage, they
Casumpang ordered the conduct of hematocrit, hemoglobin, blood should have referred the patient to another doctor
typing, blood transfusion and tourniquet tests. These tests came with sufficient training and experience instead of
too late, as proven by: (1) the blood test results that came at about assuring him and his mother that everything was all
6:00 in the evening, confirming that Edmer's illness had developed right. [Emphasis supplied]
to "Dengue Hemorrhagic Fever;" and (2) Dr. Jaudian's testimony
Even assuming that Edmer's symptoms completely
that "dengue fever could have been detected earlier than 7:30 in
coincided with the diagnosis of bronchopneumonia (so that this
the evening of April 23, 1988 because the symptoms were already
diagnosis could not be considered "wrong"), we still find Dr.
evident." 62
Casumpang guilty of negligence.
In Spouses Flores v. Spouses Pineda, 63 a case involving
First, we emphasize that we do not decide the
a medical malpractice suit, the Court ruled that the petitioner
correctness of a doctor's diagnosis, or the accuracy of the
doctors were negligent because they failed to immediately order
medical findings and treatment. Our duty in medical malpractice
tests to confirm the patient's illness. Despite the doctors' suspicion
cases is to decide — based on the evidence adduced and expert
that the patient could be suffering from diabetes, the former still
opinion presented — whether a breach of duty took place.
proceeded to the D&C operation. In that case, expert testimony
showed that tests should have been ordered immediately on Second, we clarify that a wrong diagnosis is not by
admission to the hospital in view of the symptoms presented. The itself medical malpractice. 65 Physicians are generally not liable
Court held: for damages resulting from a bona fide error of judgment.
Nonetheless, when the physician's erroneous diagnosis was the
When a patient exhibits symptoms typical of
result of negligent conduct (e.g., neglect of medical history, failure
a particular disease, these symptoms should, at the
to order the appropriate tests, failure to recognize symptoms), it
very least, alert the physician of the possibility that
becomes an evidence of medical malpractice.
the patient may be afflicted with the suspected
disease.
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 Third, we also note that medicine is not an exact Q: Now, after entertaining — After considering that
science; 66 and doctors, or even specialists, are not expected to the patient Edmer Cortero was already
give a 100% accurate diagnosis in treating patients who come to suffering from dengue hemorrhagic fever,
their clinic for consultations. Error is possible as the exercise of what did you do, if any? ICHDca
judgment is called for in considering and reading the exhibited
A: We ordered close monitoring of the blood
symptoms, the results of tests, and in arriving at definitive
pressure, the cardiac rate and respiratory
conclusions. But in doing all these, the doctor must have acted
rate of the patient.
according to acceptable medical practice standards.
Q: Now, was your instructions carried on?
In the present case, evidence on record established that in
confirming the diagnosis of bronchopneumonia, Dr. Casumpang A: Yes, sir.
selectively appreciated some and not all of the symptoms Q: What was the blood pressure of the patient?
presented, and failed to promptly conduct the appropriate tests to
confirm his findings. In sum, Dr. Casumpang failed to timely detect A: During those times, the blood pressure of the
dengue fever, which failure, especially when reasonable prudence patient was even normal during those times.
would have shown that indications of dengue were evident and/or Q: How about the respiratory rate?
foreseeable, constitutes negligence.
A: The respiratory rate was fast because the patient
a. Negligence in the Treatment and Management of in the beginning since admission had difficulty
Dengue in breathing.
Apart from failing to promptly detect dengue fever, Dr. Q: Then, after that, what did you do with the
Casumpang also failed to promptly undertake the proper patient? Doctor?
medical management needed for this disease.
A: We transfused platelet concentrate and at the
As Dr. Jaudian opined, the standard medical procedure same time, we monitor [sic] the patient.
once the patient had exhibited the classic symptoms of dengue
fever should have been: oxygen inhalation, use of analgesic, and Q: Then, who monitor [sic] the patient?
infusion of fluids or dextrose; 67 and once the patient had twice A: The pediatric resident on duty at that time.
vomited fresh blood, the doctor should have ordered: blood
transfusion, monitoring of the patient every 30 Q: Now, what happened after that?
minutes, hemostatic to stop bleeding, and oxygen if there is Q: While monitoring the patient, all his vital signs
difficulty in breathing. 68 were _____; his blood pressure was normal
Dr. Casumpang failed to measure up to these standards. so we continued with the supportive
The evidence strongly suggests that he ordered a transfusion of management at that time.
platelet concentrate instead of blood transfusion. The tourniquet Q: Now, after that?
test was only conducted after Edmer's second episode of
bleeding, and the medical management (as reflected in the A: In the evening of April 23, 1988, I stayed in the
records) did not include antibiotic therapy and complete physical hospital and I was informed by the pediatric
examination. resident on duty at around 11:15 in the
evening that the blood pressure of the patient
Dr. Casumpang's testimony states: went down to .60 palpatory.
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 Q: What did you do upon receipt of that In his testimony, Dr. Pasion declared that resident
information? applicants are generally doctors of medicine licensed to practice in
the Philippines and who would like to pursue a particular
A: I immediately went up to the room of the
specialty. 70 They are usually the front line doctors responsible for
patient and we changed the IV fluid from
the first contact with the patient. During the scope of the residency
the present fluid which was D5 0.3 sodium
program, 71 resident physicians (or "residents") 72 function under
chloride to lactated ringers solution.
the supervision of attending physicians 73 or of the hospital's
Q: You mean to say you increased the teaching staff. Under this arrangement, residents operate merely
dengue [sic] of the intervenus [sic] fluid? as subordinates who usually defer to the attending physician on
A: We changed the IV fluid because lactated the decision to be made and on the action to be taken.
ringers was necessary to resume the The attending physician, on the other hand, is primarily
volume and to bring back the blood responsible for managing the resident's exercise of duties. While
pressure, to increase the blood pressure. attending and resident physicians share the collective
[Emphasis supplied] responsibility to deliver safe and appropriate care to the
Although Dr. Casumpang presented the testimonies of Dr. patients, 74 it is the attending physician who assumes the
Rodolfo Jagonap and Dr. Ellewelyn Pasion (Dr. Pasion), principal responsibility of patient care. 75 Because he/she
Personnel Officer and Medical Director of SJDH, respectively as exercises a supervisory role over the resident, and is ultimately
well as the testimonies of Dr. Livelo and Dr. Reyes (the radiologist responsible for the diagnosis and treatment of the patient, the
who read Edmer's chest x-ray result), these witnesses failed to standards applicable to and the liability of the resident for medical
dispute the standard of action that Dr. Jaudian established in his malpractice is theoretically less than that of the attending
expert opinion. We cannot consider them expert witnesses either physician. These relative burdens and distinctions, however, do
for the sole reason that they did not testify on the standard of care not translate to immunity from the legal duty of care for
in dengue cases. 69 residents, 76 or from the responsibility arising from their own
negligent act.
On the whole, after examining the totality of the adduced
evidence, we find that the lower courts correctly did not rely on Dr. In Jenkins v. Clark, 77 the Ohio Court of Appeals held that
Casumpang's claim that he exercised prudence and due diligence the applicable standard of care in medical malpractice cases
in handling Edmer's case. Aside from being self-serving, his claim involving first-year residents was that of a reasonably prudent
is not supported by competent evidence. As the lower courts did, physician and not that of interns. According to Jenkins:
we rely on the uncontroverted fact that he failed, as a medical It is clear that the standard of care required
professional, to observe the most prudent medical procedure of physicians is not an individualized one but of
under the circumstances in diagnosing and treating Edmer. physicians in general in the community. In order to
Dr. Miranda is Not Liable for Negligence establish medical malpractice, it must be shown by
a preponderance of the evidence that a physician
In considering the case of Dr. Miranda, the junior resident did some particular thing or things that a physician
physician who was on-duty at the time of Edmer's confinement, or surgeon of ordinary skill, care and diligence
we see the need to draw distinctions between the responsibilities would not have done under like or similar
and corresponding liability of Dr. Casumpang, as the attending conditions or circumstances, or that he failed or
physician, and that of Dr. Miranda. TCAScE omitted to do some particular thing or things that a
physician or surgeon of ordinary skill, care and
12 | P a g e
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 diligence would have done under like or similar Edmer's second episode of bleeding — that Edmer could be
conditions or circumstances, and that the inquiry suffering from dengue fever, she wasted no time in conducting the
complained of was the direct result of such doing or necessary tests, and promptly notified Dr. Casumpang about the
failing to do such thing or things. incident. Indubitably, her medical assistance led to the finding of
dengue fever.
We note that the standard of instruction
given by the court was indeed a proper one. It We note however, that during Edmer's second episode of
clearly informed the jury that the medical care bleeding, 81 Dr. Miranda failed to immediately examine and note
required is that of reasonably careful the cause of the blood specimen. Like Dr. Casumpang, she
physicians or hospital emergency room merely assumed that the blood in Edmer's phlegm was caused by
operators, not of interns or residents. [Emphasis bronchopneumonia. Her testimony states:
supplied]
TSN, June 8, 1993:
A decade later, Centman v. Cobb, 78 affirmed
Q: Let us get this clear, you said that the father told
the Jenkins ruling and held that interns and first-year residents are
you the patient cocked [sic] out phlegm.
"practitioners of medicine required to exercise the same standard
of care applicable to physicians with unlimited licenses to A: With blood streak.
practice." The Indiana Court held that although a first-year Q: Now, you stated specimen, were you not able
resident practices under a temporary medical permit, he/she to examine the specimen?
impliedly contracts that he/she has the reasonable and ordinary
qualifications of her profession and that he/she will exercise A: No, sir, I did not because according to the
reasonable skill, diligence, and care in treating the patient. father he wash [sic] his hands.
We find that Dr. Miranda was not independently xxx xxx xxx
negligent. Although she had greater patient exposure, and was Q: Now, from you knowledge, what does that indicate
subject to the same standard of care applicable to attending if the patient expels a phlegm and blood
physicians, we believe that a finding of negligence should also streak?
depend on several competing factors, among them, her authority
to make her own diagnosis, the degree of supervision of the A: If a patient cocked [sic] out phlegm then the
attending physician over her, and the shared responsibility specimen could have come from the lung
between her and the attending physicians. alone. 82 [Emphasis supplied]
In this case, before Dr. Miranda attended to Edmer, both xxx xxx xxx
Dr. Livelo and Dr. Casumpang had diagnosed Edmer with TSN, June 17, 1993:
bronchopneumonia. In her testimony, Dr. Miranda admitted that
she had been briefed about Edmer's condition, his medical history, Q: Now, in the first meeting you had, when that was
and initial diagnosis; 79 and based on these pieces of information, relayed to you by the father that Edmer
she confirmed the finding of bronchopneumonia. cTDaEH Cortejo had coughed out blood, what medical
action did you take?
Dr. Miranda likewise duly reported to Dr. Casumpang, who
admitted receiving updates regarding Edmer's condition. 80 There A: I examined the patient and I thought that, that
is also evidence supporting Dr. Miranda's claim that she extended coughed out phlegm was a product of
diligent care to Edmer. In fact, when she suspected — during broncho pneumonia.
13 | P a g e
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 xxx xxx xxx training that qualify him/her to explain highly technical
medical matters to the Court.
Q: So what examination did you specifically conduct
to see that there was no internal bleeding? In Ramos v. Court of Appeals, 85 the Court found the
expert witness, who is a pulmonologist, not qualified to testify on
A: At that time I did not do anything to determine
the field of anesthesiology. Similarly, in Cereno v. Court of
the cause of coughing of the blood
Appeals, 86 a 2012 case involving medical negligence, the Court
because I presumed that it was a
excluded the testimony of an expert witness whose specialty was
mucous (sic) produced by broncho
anesthesiology, and concluded that an anesthesiologist cannot be
pneumonia, And besides the patient did
considered an expert in the field of surgery or even in surgical
not even show any signs of any other
practices and diagnosis.
illness at that time. 83
Interestingly in this case, Dr. Jaudian, the expert witness
Based on her statements we find that Dr. Miranda was not
was admittedly not a pediatrician but a practicing physician who
entirely faultless. Nevertheless, her failure to discern the
specializes in pathology. 87 He likewise does not possess any
import of Edmer's second bleeding does not necessarily
formal residency training in pediatrics. Nonetheless, both the
amount to negligence as the respondent himself admitted that
lower courts found his knowledge acquired through study and
Dr. Miranda failed to examine the blood specimen because he
practical experience sufficient to advance an expert opinion on
washed it away. In addition, considering the diagnosis previously
dengue-related cases.
made by two doctors, and the uncontroverted fact that the burden
of final diagnosis pertains to the attending physician (in this case, We agree with the lower courts.
Dr. Casumpang), we believe that Dr. Miranda's error was merely
A close scrutiny of Ramos and Cereno reveals that the
an honest mistake of judgment influenced in no small measure by
Court primarily based the witnesses' disqualification to testify as
her status in the hospital hierarchy; hence, she should not be held
an expert on their incapacity to shed light on the standard of care
liable for medical negligence. cSaATC
that must be observed by the defendant physicians. That the
Dr. Jaudian's Professional Competence and Credibility expert witnesses' specialties do not match the physicians' practice
area only constituted, at most, one of the considerations that
One of the critical issues the petitioners raised in the
should not be taken out of context. After all, the sole function of a
proceedings before the lower court and before this Court was Dr.
medical expert witness, regardless of his/her specialty, is to afford
Jaudian's competence and credibility as an expert witness. The
assistance to the courts on medical matters, and to explain the
petitioners tried to discredit his expert testimony on the ground
medical facts in issue. CHTAIc
that he lacked the proper training and fellowship status in
pediatrics. Furthermore, there was no reasonable indication
in Ramos and Cereno that the expert witnesses possess a
• Criteria in Qualifying as an Expert Witness
sufficient familiarity with the standard of care applicable to the
The competence of an expert witness is a matter for the physicians' specialties.
trial court to decide upon in the exercise of its discretion. The test
US jurisprudence on medical malpractice demonstrated
of qualification is necessarily a relative one, depending upon the
the trial courts' wide latitude of discretion in allowing a specialist
subject matter of the investigation, and the fitness of the expert
from another field to testify against a defendant specialist.
witness. 84 In our jurisdiction, the criterion remains to be the
expert witness' special knowledge experience and practical In Brown v. Sims, 88 a neurosurgeon was found
competent to give expert testimony regarding a gynecologist's
14 | P a g e
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 standard of pre-surgical care. In that case, the court held that subject; and (2) is familiar with the standard
since negligence was not predicated on the gynecologist's required of a physician under similar
negligent performance of the operation, but primarily on the claim circumstances; where a witness has disclosed
that the pre-operative histories and physicals were inadequate, sufficient knowledge of the subject to entitle his
the neurosurgeon was competent to testify as an expert. opinion to go to the jury, the question of the degree
of his knowledge goes more to the weight of the
Frost v. Mayo Clinic 89 also allowed an orthopedic surgeon
evidence than to its admissibility.
to testify against a neurologist in a medical malpractice action.
The court considered that the orthopedic surgeon's opinion on the xxx xxx xxx
"immediate need for decompression" need not come from a
Nor is it critical whether a medical expert is
specialist in neurosurgery. The court held that:
a general practitioner or a specialist so long as he
It is well established that "the testimony of a exhibits knowledge of the subject. Where a duly
qualified medical doctor cannot be excluded simply licensed and practicing physician has gained
because he is not a specialist . . . ." The matter of ". knowledge of the standard of care applicable to
. . training and specialization of the witness goes to a specialty in which he is not directly engaged
the weight rather than admissibility . . . ." but as to which he has an opinion based on
education, experience, observation, or
xxx xxx xxx
association wit that specialty, his opinion is
It did not appear to the court that a medical doctor competent. (Emphasis supplied) EATCcI
had to be a specialist in neurosurgery to express
Finally, Brown v. Mladineo 92 adhered to the principle that
the opinions permitted to be expressed by plaintiffs'
the witness' familiarity, and not the classification by title or
doctors, e.g., the immediate need for a
specialty, which should control issues regarding the expert
decompression in the light of certain neurological
witness' qualifications:
deficits in a post-laminectomy patient. As stated
above, there was no issue as to the proper The general rule as to expert testimony in
execution of the neurosurgery. The medical medical malpractice actions is that "a specialist in a
testimony supported plaintiffs' theory of negligence particular branch within a profession will not be
and causation. (Citations omitted) required." Most courts allow a doctor to testify if
they are satisfied of his familiarity with the
In another case, 90 the court declared that it is
standards of a specialty, though he may not
the specialist's knowledge of the requisite subject matter,
practice the specialty himself. One court explained
rather than his/her specialty that determines his/her
that "it is the scope of the witness' knowledge and
qualification to testify.
not the artificial classification by title that should
Also in Evans v. Ohanesian, 91 the court set a guideline in govern the threshold question of admissibility.
qualifying an expert witness: (Citations omitted)
To qualify a witness as a medical expert, it • Application to the Present Case
must be shown that the witness (1) has the
In the case and the facts before us, we find that Dr.
required professional knowledge, learning and
Jaudian is competent to testify on the standard of care in dengue
skill of the subject under inquiry sufficient to
fever cases.
qualify him to speak with authority on the
15 | P a g e
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 Although he specializes in pathology, it was established care and management needed for dengue fever, the risk of
during trial that he had attended not less than 30 seminars held by complications or even death, could have been substantially
the Pediatric Society, had exposure in pediatrics, had been reduced.
practicing medicine for 16 years, and had handled not less than
Furthermore, medical literature on dengue shows that early
50 dengue related cases.
diagnosis and management of dengue is critical in reducing the
As a licensed medical practitioner specializing in risk of complications and avoiding further spread of the
pathology, who had practical and relevant exposure in pediatrics virus. 96 That Edmer later died of "Hypovolemic
and dengue related cases, we are convinced that Dr. Jaudian Shock/hemorrhagic shock," "Dengue Hemorrhagic Fever Stage
demonstrated sufficient familiarity with the standard of care to be IV," a severe and fatal form of dengue fever, established the
applied in dengue fever cases. Furthermore, we agree that he causal link between Dr. Casumpang's negligence and the injury.
possesses knowledge and experience sufficient to qualify him to
Based on these considerations, we rule that the
speak with authority on the subject.
respondent successfully proved the element of causation.
The Causation between Dr. Casumpang's
Liability of SJDH
Negligent Act/Omission, and the Patient's
Resulting Death was Adequately Proven We now discuss the liability of the hospital.
Dr. Jaudian's testimony strongly suggests that due to Dr. The respondent submits that SJDH should not only be held
Casumpang's failure to timely diagnose Edmer with dengue, the vicariously liable for the petitioning doctors' negligence but also for
latter was not immediately given the proper treatment. In fact, its own negligence. He claims that SJDH fell short of its duty of
even after Dr. Casumpang had discovered Edmer's real illness, he providing its patients with the necessary facilities and equipment
still failed to promptly perform the standard medical procedure. as shown by the following circumstances: DHITCc
We agree with these findings. (a) SJDH was not equipped with proper paging system;
As the respondent had pointed out, dengue fever, if left (b) the number of its doctors is not proportionate to the
untreated, could be a life threatening disease. As in any fatal number of patients;
diseases, it requires immediate medical attention. 93 With the
correct and timely diagnosis, coupled with the proper medical (c) SJDH was not equipped with a bronchoscope;
management, dengue fever is not a life-threatening disease and (d) when Edmer's oxygen was removed, the medical staff
could easily be cured. 94 did not immediately provide him with portable
Furthermore, as Dr. Jaudian testified, with adequate oxygen;
intensive care, the mortality rate of dengue fever should fall to less (e) when Edmer was about to be transferred to another
than 2%. Hence, the survival of the patient is directly related to hospital, SJDH's was not ready and had no driver;
early and proper management of the illness. 95 and
To reiterate, Dr. Casumpang failed to timely diagnose (f) despite Edmer's critical condition, there was no doctor
Edmer with dengue fever despite the presence of its characteristic attending to him from 5:30 p.m. of April 22, to 9:00
symptoms; and as a consequence of the delayed diagnosis, he a.m. of April 23, 1988.
also failed to promptly manage Edmer's illness. Had he
immediately conducted confirmatory tests, (i.e., tourniquet tests
and series of blood tests) and promptly administered the proper

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 SJDH on the other hand disclaims liability by claiming that The US case of Gilbert v. Sycamore Municipal
the petitioning doctors are not its employees but are mere Hospital 100 abrogated the hospitals' immunity to vicarious liability
consultants and independent contractors. of independent contractor physicians. In that case, the Illinois
Supreme Court held that under the doctrine of apparent authority,
We affirm the hospital's liability not on the basis of Article
hospitals could be found vicariously liable for the negligence of an
2180 of the Civil Code, but on the basis of the doctrine of apparent
independent contractor: cEaSHC
authority or agency by estoppel.
Therefore, we hold that, under the doctrine
There is No Employer-Employee Relationship
of apparent authority, a hospital can be held
between SJDH and the Petitioning Doctors
vicariously liable for the negligent acts of a
In determining whether an employer-employee relationship physician providing care at the hospital, regardless
exists between the parties, the following elements must be of whether the physician is an independent
present: (1) selection and engagement of services; (2) payment of contractor, unless the patient knows, or should
wages; (3) the power to hire and fire; and (4) the power to control have known, that the physician is an independent
not only the end to be achieved, but the means to be used in contractor. The elements of the action have been
reaching such an end. 97 set out as follows:
Control, which is the most crucial among the elements, is For a hospital to be liable under the
not present in this case. doctrine of apparent authority, a
Based on the records, no evidence exists showing that plaintiff must show that: (1) the
SJDH exercised any degree of control over the means, methods hospital, or its agent, acted in a
of procedure and manner by which the petitioning doctors manner that would lead a
conducted and performed their medical profession. SJDH did not reasonable person to conclude
control their diagnosis and treatment. Likewise, no evidence was that the individual who was
presented to show that SJDH monitored, supervised, or directed alleged to be negligent was an
the petitioning doctors in the treatment and management of employee or agent of the hospital;
Edmer's case. In these lights, the petitioning doctors were not (2) where the acts of the agent
employees of SJDH, but were mere independent contractors. create the appearance of
authority, the plaintiff must also
SJDH is Solidarily Liable Based prove that the hospital had
on the Principle of Agency or Doctrine knowledge of and acquiesced in
of Apparent Authority them; and (3) the plaintiff acted in
Despite the absence of employer-employee relationship reliance upon the conduct of the
between SJDH and the petitioning doctors, SJDH is not free from hospital or its agent, consistent
liability. 98 with ordinary care and
prudence. (Emphasis supplied)
As a rule, hospitals are not liable for the negligence of its
independent contractors. However, it may be found liable if the The doctrine was applied in Nogales v. Capitol Medical
physician or independent contractor acts as an ostensible agent of Center 101 where this Court, through the ponencia of Associate
the hospital. This exception is also known as the "doctrine of Justice Antonio T. Carpio, discussed the two factors in
apparent authority." 99 determining hospital liability as follows:

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 The first factor focuses on the hospital's (1) the hospital, by providing emergency room care and by
manifestations and is sometimes described as an failing to advise patients that they were being
inquiry whether the hospital acted in a manner treated by the hospital's agent and not its
which would lead a reasonable person to conclude employee, has created the appearance of agency;
that the individual who was alleged to be negligent and
was an employee or agent of the hospital. In this
(2) patients entering the hospital through the emergency
regard, the hospital need not make express
room, could properly assume that the treating
representations to the patient that the treating
doctors and staff of the hospital were acting on its
physician is an employee of the hospital; rather a
behalf.
representation may be general and implied.
In this case, the court considered the act of the hospital of
xxx xxx xxx
holding itself out as provider of complete medical care, and
The second factor focuses on the patient's considered the hospital to have impliedly created the appearance
reliance. It is sometimes characterized as an of authority.
inquiry on whether the plaintiff acted in reliance
b. Patient's reliance
upon the conduct of the hospital or its agent,
consistent with ordinary care and prudence. It involves an inquiry on whether the plaintiff acted in
(Citation omitted) reliance on the conduct of the hospital or its agent, consistent with
ordinary care and prudence. 104
In sum, a hospital can be held vicariously liable for the
negligent acts of a physician (or an independent contractor) In Pamperin, the court held that the important
providing care at the hospital if the plaintiff can prove these two consideration in determining the patient's reliance is: whether the
factors: first, the hospital's manifestations; and second, the plaintiff is seeking care from the hospital itself or whether the
patient's reliance. plaintiff is looking to the hospital merely as a place for his/her
personal physician to provide medical care. 105
a. Hospital's manifestations
Thus, this requirement is deemed satisfied if the plaintiff
It involves an inquiry on whether the hospital acted in a
can prove that he/she relied upon the hospital to provide care and
manner that would lead a reasonable person to conclude that the
treatment, rather than upon a specific physician. In this case, we
individual alleged to be negligent was an employee or agent of the
shall limit the determination of the hospital's apparent authority to
hospital. As pointed out in Nogales, the hospital need not make
Dr. Casumpang, in view of our finding that Dr. Miranda is not liable
express representations to the patient that the physician or
for negligence. CTIEac
independent contractor is an employee of the hospital;
representation may be general and implied. 102 SJDH Clothed Dr. Casumpang with Apparent Authority
In Pamperin v. Trinity Memorial Hospital, 103 questions SJDH impliedly held out and clothed Dr. Casumpang with
were raised on "what acts by the hospital or its agent are sufficient apparent authority leading the respondent to believe that he is an
to lead a reasonable person to conclude that the individual was an employee or agent of the hospital.
agent of the hospital." In ruling that the hospital's manifestations Based on the records, the respondent relied on SJDH
can be proven without the express representation by the hospital, rather than upon Dr. Casumpang, to care and treat his son Edmer.
the court relied on several cases from other jurisdictions, and held His testimony during trial showed that he and his wife did not
that: know any doctors at SJDH; they also did not know that Dr.
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 Casumpang was an independent contractor. They brought their and the Resolution dated January 12, 2006 in CA-G.R. CV No.
son to SJDH for diagnosis because of their family doctor's referral. 56400.
The referral did not specifically point to Dr. Casumpang or even to
SO ORDERED.
Dr. Miranda, but to SJDH.
Carpio, Villarama, Jr., * Mendoza and Leonen, JJ., concur.
Significantly, the respondent had relied on SJDH's
representation of Dr. Casumpang's authority. To recall, when Mrs. ||| (Casumpang v. Cortejo, G.R. Nos. 171127, 171217 & 17122,
Cortejo presented her Fortune Care card, she was initially referred [March 11, 2015], 752 PHIL 379-433)
to the Fortune Care coordinator, who was then out of town. She
was thereafter referred to Dr. Casumpang, who is also accredited
with Fortune Care. In both instances, SJDH through its agent
failed to advise Mrs. Cortejo that Dr. Casumpang is an
independent contractor.
Mrs. Cortejo accepted Dr. Casumpang's services on the
reasonable belief that such were being provided by SJDH or its
employees, agents, or servants. By referring Dr. Casumpang to
care and treat for Edmer, SJDH impliedly held out Dr.
Casumpang, not only as an accredited member of Fortune
Care, but also as a member of its medical staff. SJDH cannot
now disclaim liability since there is no showing that Mrs. Cortejo or
the respondent knew, or should have known, that Dr. Casumpang
is only an independent contractor of the hospital. In this case,
estoppel has already set in.
We also stress that Mrs. Cortejo's use of health care plan
(Fortune Care) did not affect SJDH's liability. The only effect of the
availment of her Fortune Care card benefits is that her choice of
physician is limited only to physicians who are accredited with
Fortune Care. Thus, her use of health care plan in this case only
limited the choice of doctors (or coverage of services, amount,
etc.) and not the liability of doctors or the hospital.
WHEREFORE, premises considered, this Court PARTLY
GRANTS the consolidated petitions. The Court finds Dr. Noel
Casumpang and San Juan de Dios Hospital solidarily liable for
negligent medical practice. We SET ASIDE the finding of liability
as to Dr. Ruby Sanga-Miranda. The amounts of P45,000.00 as
actual damages and P500,000.00 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 October 29, 2004
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