DR. EDUARDO AQUINO, PETITIONER, VS. HEIRS OF RAYMUNDA CALAYAG, NAMELY: RODRIGO, WILMA, WILLIE, WILLIAM, WILSON, WENDY, WHITNEY AND WARREN, ALL SURNAMED CALAYAG, REPRESENTED BY R…

Aquino versus Calayag

The Case

This is a medical malpractice case. The heirs of Raymunda Calayag sued three doctors for damages after Raymunda went into a coma following a caesarean section and later died. The surgeon, the anesthesiologist, and the hospital owner were all impleaded. The case matters because it gathers in one decision the whole architecture of medical negligence: the four elements a plaintiff must prove, the weight given to expert testimony, the duty of a surgeon to supervise those who assist in the operation, and the limits of a hospital owner's liability for the acts of independent, self-employed physicians who merely use its facilities.

Procedural History

The heirs filed a complaint for damages before the Regional Trial Court of Malolos against Dr. Divinia Unite, the surgeon, Dr. Eduardo Aquino, the anesthesiologist, and Dr. Alberto Reyes, the owner of Sacred Heart Hospital. After hearing the parties on their evidence, the trial court rendered judgment in August 1994, finding all three doctors liable for negligence. It held that the proximate cause of Raymunda's cardiac arrest was an anesthetic accident caused by a high spinal anesthesia, and that the operating doctors failed to correctly monitor her condition, causing a critical delay in resuscitation. The trial court ordered the doctors to pay actual damages, moral damages, and attorney's fees with costs.

On appeal, the Court of Appeals entirely affirmed the findings of the trial court. The doctors then filed separate petitions for review before the Supreme Court, which were consolidated. The Supreme Court decided the case in August 2012.

Facts

On November 13, 1990, Raymunda Calayag went into labor and began bleeding. Her husband Rodrigo brought her to St. Michael's Clinic in Malolos, Bulacan, owned by Dr. Unite. After examination, Dr. Unite told Rodrigo that a caesarean section was needed, but that it had to be done at the better-equipped Sacred Heart Hospital, owned by Dr. Reyes. The hospital admitted Raymunda that afternoon. Dr. Aquino, the attending anesthesiologist, injected her with a preliminary hypnotic at about half past two, and administered anesthesia on her spine at about quarter to three. At about three o'clock, Dr. Unite delivered a stillborn eight-month-old baby.

Minutes later, the operating team noticed that Raymunda had become cyanotic. Her blood darkened for lack of oxygen, and her vital signs suddenly disappeared. The team worked on her for about five to seven minutes until her vital signs were restored. When Rodrigo saw her after the operation, her skin appeared dark and the whites of her eyes showed. Dr. Unite told him this was merely the effect of the anesthesia and that she would regain consciousness in about eight hours. She did not improve. An internist found that she had suffered a cardiac arrest during the operation, and a neurologist advised that she be moved to a better-equipped hospital. She was discharged four days after admission and brought to Medical Center Manila, where a neurologist found her in a vegetative state due to an anoxic injury from cardio-respiratory arrest during the operation.

On November 23, 1990, Dr. Unite removed the stitches from the surgical wound. Later that day the wound split open, causing part of Raymunda's intestines to jut out, and another surgeon re-sutured it. Raymunda never regained consciousness. She was discharged at the end of November and died fifteen days later, on December 14, 1990. Her husband and seven children then sued the three doctors for damages.

Issues

• Whether or not Dr. Unite, the surgeon, and Dr. Aquino, the anesthesiologist, acted negligently in handling Raymunda's operation, resulting in her death.
• Whether or not Dr. Reyes is liable, as hospital owner, for the negligence of Dr. Unite and Dr. Aquino.

Applicable Provisions

Article 2206 of the Civil Code provides:

The amount of damages for death caused by a crime or quasi-delict shall be at least three thousand pesos, even though there may have been mitigating circumstances. In addition: (1) The defendant shall be liable for the loss of the earning capacity of the deceased, and the indemnity shall be paid to the heirs of the latter; such indemnity shall in every case be assessed and awarded by the court, unless the deceased on account of permanent physical disability not caused by the defendant, had no earning capacity at the time of his death; (2) If the deceased was obliged to give support according to the provisions of Article 291, the recipient or recipients who are deprived of support by reason of the death of the deceased, may demand support from the defendant, for a period not exceeding five years, the exact duration to be fixed by the court; (3) The defendant is also obliged to pay the surviving spouse and the illegitimate descendants of the deceased moral damages for mental anguish by reason of the death of the deceased.

This is the basis on which the Court awarded the heirs a death indemnity of 50,000 pesos, in addition to the damages already affirmed.

Ruling

On the first issue, the Court held that both Dr. Unite and Dr. Aquino were negligent. It began by defining the cause of action. Medical malpractice is a form of negligence consisting in the physician's or surgeon's failure to apply to his practice that degree of care and skill that the profession generally and ordinarily employs under similar conditions and circumstances. To succeed, the plaintiff must establish four basic things: duty, breach, injury, and proximate causation. The evidence must show that the physician failed to do something a reasonably prudent physician would have done, or did something a reasonably prudent physician would not have done, and that this caused injury to the patient.

The Court relied on the testimony of Dr. Libarnes, the attending neurologist, and Dr. Chua, the surgeon who re-stitched the wound. Dr. Libarnes explained that cyanosis, or lack of oxygen in the brain, caused the vegetative state, and that the cardio-respiratory arrest could be traced to the anesthetic accident that resulted when Dr. Aquino placed Raymunda under anesthesia. He also blamed the operating doctors for not properly keeping track of her vital signs, resulting in a failure to promptly address the cyanosis. Dr. Chua testified that the wound would not have split open had it been properly closed.

The Court discounted the testimony of Dr. Reyes, who testified for his co-defendants. Although the Court did not question his expertise as a general surgeon, it could not regard him as a neutral witness, given that he was himself a defendant with a natural bias to favor his co-defendants. He also had no opportunity to examine Raymunda and could only invoke textbook principles. Dr. Libarnes, as a neurologist with expertise in the brain, was in a better position to explain the vegetative condition and its cause.

The Court also held that Dr. Unite could not exempt herself from liability. Dr. Aquino was not feeling well on the day of the operation and was in fact on sick leave. As surgeon in charge, Dr. Unite should not have allowed him to take part in the operation. Moreover, the record of the operation contained no notation of just when Raymunda had a cardio-respiratory arrest and ceased to take in oxygen. That notation was critical, since the surgeons had between six and eight minutes from the time of arrest, called the golden period of reversibility, within which to save her from becoming a vegetable. The absence of that entry implies that the surgeons had no inkling when the arrest occurred and how much time they had left to revive their patient.

On the second issue, the Court held Dr. Reyes not liable. There was no concrete proof that Dr. Unite and Dr. Aquino were on the hospital's payroll. Dr. Aquino appeared to be a government physician, and Dr. Unite a self-employed doctor. The hospital allowed them to operate on their patients, using its operating room and assisting staff for a fee. No evidence showed that Raymunda suffered her fate because of defective hospital facilities or poor staff support. That Dr. Reyes and his wife rushed to the operating room when they heard that Raymunda's vital signs had ceased was not evidence of supervision over the operation; they evidently came to see what was happening, possibly to help if needed.

The Court also rejected the doctrine of ostensible agency, or apparent authority. Two factors must be present: first, the hospital acted in a manner which would lead a reasonable person to believe that the person claimed to be negligent was its agent or employee; and second, the patient relied on such belief. Here, there was no evidence that the hospital acted in a way that made Raymunda and her husband believe that the two doctors were in its employ. The couple had been consulting Dr. Unite at her own clinic, and she convinced them that the caesarean section had to be performed at Sacred Heart Hospital because it had the required facilities. To allow damages against the hospital under this arrangement would unreasonably deny independently licensed surgeons access to properly equipped operating rooms in big hospitals.

Doctrine

First, medical malpractice is a form of negligence consisting in the physician's or surgeon's failure to apply to his practice that degree of care and skill that the profession generally and ordinarily employs under similar conditions and circumstances. Second, the plaintiff must establish four elements: duty, breach, injury, and proximate causation. Third, the Court seeks guidance from expert testimonies, and a physician-defendant testifying for co-defendants is not a neutral witness. Fourth, the surgeon in charge has the duty not to allow an ailing anesthesiologist to take part in the operation, and failure to maintain complete, timely, and accurate records can itself constitute medical malpractice. Fifth, a hospital owner is not liable for the negligence of independent, self-employed physicians who merely use its facilities, absent proof of an employer-employee relationship or of ostensible agency, which requires both that the hospital acted in a manner leading a reasonable person to believe the negligent doctor was its agent or employee, and that the patient relied on that belief. Sixth, under Article 2206 of the Civil Code, the heirs of the deceased are entitled to a death indemnity of 50,000 pesos.

Disposition

The Supreme Court denied the petitions and affirmed the decision of the Court of Appeals, with modification directing Dr. Unite and Dr. Aquino to pay the heirs of Raymunda Calayag, in addition to the damages already awarded, 50,000 pesos as death indemnity. Dr. Reyes, the hospital owner, was absolved.

Remember This

Memorize the four elements of medical malpractice, duty, breach, injury, and proximate causation, together with the two-factor test for ostensible agency that shields the hospital owner. Examiners like to use this case on the liability of the surgeon for the acts of the anesthesiologist, on the evidentiary weight of expert testimony from a co-defendant, and on the non-liability of hospitals for independent physicians who merely use their operating rooms.