G.R. No. 171127. March 11, 2015.

*
 
NOEL CASUMPANG, RUBY SANGA-MIRANDA and SAN
JUAN DE DIOS HOSPITAL, petitioners, vs. NELSON CORTEJO,
respondent.

G.R. No. 171217. March 11, 2015.*

 
DRA. RUBY SANGA-MIRANDA, petitioner, vs. NELSON
CORTEJO, respondent.

_______________

*  SECOND DIVISION.

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380 SUPREME COURT REPORTS ANNOTATED

Casumpang vs. Cortejo

G.R. No. 171228. March 11, 2015.*

 
SAN JUAN DE DIOS HOSPITAL, petitioner, vs. NELSON
CORTEJO, respondent.

Remedial Law; Civil Procedure; Appeals; Petition for Review on

Certiorari; The settled rule is that the Court’s jurisdiction in a petition for
review on certiorari under Rule 45 of the Rules of Court is limited only to
the review of pure questions of law.—The settled rule is that the Court’s
jurisdiction in a petition for review on certiorari under Rule 45 of the Rules
of Court is limited only to the review of pure questions of law. It is not the
Court’s function to inquire on the veracity of the appellate court’s factual
findings and conclusions; this Court is not a trier of facts. 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 when the doubt arises as to the truth or
falsity of the alleged facts.
 Civil Law; Quasi-Delicts; Medical Malpractice; Negligence; To
successfully pursue a medical malpractice suit, the plaintiff (in this case, the
deceased patient’s heir) must prove that the doctor either failed to do what a
reasonably prudent doctor would have done, or did what a reasonably
prudent doctor would not have done; and the act or omission had caused
injury to the patient.—The claim for damages is based on the petitioning
doctors’ negligence in diagnosing and treating the deceased Edmer, the
child of the respondent. It is a medical malpractice suit, an action available
to victims to redress a wrong committed by medical professionals who
caused bodily harm to, or the death of, a patient. As the term is used, the suit
is brought whenever a medical practitioner or health care provider fails to
meet the standards demanded by his profession, or deviates from this
standard, and causes injury to the patient. To successfully pursue a medical
malpractice suit, the plaintiff (in this case, the deceased patient’s heir) must
prove that the doctor either failed to do what a reasonably prudent doctor
would have done, or did what a reasonably prudent doctor would not have
done; and the act or omission had caused injury to the patient. The patient’s
heir/s bears the burden of proving his/her cause of action.

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Same; Same; Same; Physician-Patient Relationship; A physician-

patient relationship is created when a patient engages the services of a
physician, and the latter accepts or agrees to provide care to the patient;
The mere fact that an individual approaches a physician and seeks
diagnosis, advice or treatment does not create the duty of care unless the
physician agrees.—The elements of medical negligence are: (1) duty; (2)
breach; (3) injury; and (4) proximate causation. Duty refers to the
standard of behavior that imposes restrictions on one’s conduct. It requires
proof of professional relationship between the physician and the patient.
Without the professional relationship, a physician owes no duty to the
patient, and cannot therefore incur any liability. A physician-patient
relationship is created when a patient engages the services of a physician,
and the latter accepts or agrees to provide care to the patient. The
establishment of this relationship is consensual, and the acceptance by the
physician essential. The mere fact that an individual approaches a physician
and seeks diagnosis, advice or treatment does not create the duty of care
unless the physician agrees.
Same; Same; Same; Same; Once a physician-patient relationship is
established, the legal duty of care follows. The doctor accordingly becomes
duty-bound to use at least the same standard of care that a reasonably
competent doctor would use to treat a medical condition under similar
circumstances.—Once a physician-patient relationship is established, the
legal duty of care follows. The doctor accordingly becomes duty-bound to
use at least the same standard of care that a reasonably competent doctor
would use to treat a medical condition under similar circumstances. Breach
of duty occurs when the doctor fails to comply with, or improperly performs
his duties under professional standards. This determination is both factual
and legal, and is specific to each individual case. If the patient, as a result of
the breach of duty, is injured in body or in health, actionable malpractice is
committed, entitling the patient to damages. To successfully claim damages,
the patient must lastly prove the causal relation between the negligence and
the injury. This connection must be direct, natural, and should be unbroken
by any intervening efficient causes. In other words, the negligence must be
the proximate cause of the injury. The injury or damage is proximately
caused by the physician’s negligence when it appears, based on the evidence
and the expert testimony, that the negligence played an integral part in
causing the injury or damage, and that the injury

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Casumpang vs. Cortejo

or damage was either a direct result, or a reasonably probable

consequence of the physician’s negligence.
Same; Same; Same; Same; With respect to Dr. Miranda, her
professional relationship with Edmer arose when she assumed the
obligation to provide resident supervision over the latter.—With respect to
Dr. Miranda, her professional relationship with Edmer arose when she
assumed the obligation to provide resident supervision over the latter. As
second year resident doctor tasked to do rounds and assist other physicians,
Dr. Miranda is deemed to have agreed to the creation of physician-patient
relationship with the hospital’s patients when she participated in the
diagnosis and prescribed a course of treatment for Edmer. The undisputed
evidence shows that Dr. Miranda examined Edmer twice (at around 12:00
and 3:30 in the afternoon of April 23, 1988), and in both instances, she
prescribed treatment and participated in the diagnosis of Edmer’s medical
condition. Her affirmative acts amounted to her acceptance of the physician-
patient relationship, and incidentally, the legal duty of care that went with it.
Same; Same; Same; Same; Expert Witnesses; It is in this aspect of
medical malpractice that expert testimony is essential to establish not only
the professional standards observed in the medical community, but also that
the physician’s conduct in the treatment of care falls below such standard.—
A determination of whether or not the petitioning doctors met the required
standard of care involves a question of mixed fact and law; it is factual as
medical negligence cases are highly technical in nature, requiring the
presentation of expert witnesses to provide guidance to the court on matters
clearly falling within the domain of medical science, and legal, insofar as
the Court, after evaluating the expert testimonies, and guided by medical
literature, learned treatises, and its fund of common knowledge, ultimately
determines whether breach of duty took place. Whether or not Dr.
Casumpang and Dr. Miranda committed a breach of duty is to be measured
by the yardstick of professional standards observed by the other members of
the medical profession in good standing under similar circumstances. It is in
this aspect of medical malpractice that expert testimony is essential to
establish not only the professional standards observed in the medical
community, but also that the physician’s conduct in the treatment of care
falls below such standard.

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Same; Same; Same; Same; In Spouses Flores v. Spouses Pineda, 571

SCRA 83 (2008), a case involving a medical malpractice suit, the Supreme
Court (SC) ruled that the petitioner doctors were negligent because they
failed to immediately order tests to confirm the patient’s illness.—In Spouses
Flores v. Spouses Pineda, 571 SCRA 83 (2008), a case involving a medical
malpractice suit, the Court ruled that the petitioner doctors were negligent
because they failed to immediately order tests to confirm the patient’s
illness. Despite the doctors’ suspicion that the patient could be suffering
from diabetes, the former still proceeded to the D&C operation. In that case,
expert testimony showed that tests should have been ordered immediately
on admission to the hospital in view of the symptoms presented. The Court
held: When a patient exhibits symptoms typical of a particular disease, these
symptoms should, at the very least, alert the physician of the possibility that
the patient may be afflicted with the suspected disease.
Same; Same; Same; Same; A wrong diagnosis is not by itself medical
malpractice.—Even assuming that Edmer’s symptoms completely coincided
with the diagnosis of bronchopneumonia (so that this diagnosis could not be
considered “wrong”), we still find Dr. Casumpang guilty of negligence.
First, we emphasize that we do not decide the correctness of a doctor’s
diagnosis, or the accuracy of the medical findings and treatment. Our
duty in medical malpractice cases is to decide — based on the evidence
adduced and expert opinion presented — whether a breach of duty took
place. Second, we clarify that a wrong diagnosis is not by itself medical
malpractice. Physicians are generally not liable for damages resulting from
a bona fide error of judgment. Nonetheless, when the physician’s erroneous
diagnosis was the result of negligent conduct (e.g., neglect of medical
history, failure to order the appropriate tests, failure to recognize
symptoms), it becomes an evidence of medical malpractice. Third, we also
note that medicine is not an exact science; and doctors, or even specialists,
are not expected to give a 100% accurate diagnosis in treating patients who
come to their clinic for consultations. Error is possible as the exercise of
judgment is called for in considering and reading the exhibited symptoms,
the results of tests, and in arriving at definitive conclusions. But in doing all
these, the doctor must have acted according to acceptable medical practice
standards.

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384 SUPREME COURT REPORTS ANNOTATED

Casumpang vs. Cortejo

Same; Same; Same; Same; Apart from failing to promptly detect

dengue fever, Dr. Casumpang also failed to promptly undertake the proper
medical management needed for this disease.—Apart from failing to
promptly detect dengue fever, Dr. Casumpang also failed to promptly
undertake the proper medical management needed for this disease. As Dr.
Jaudian opined, the standard medical procedure once the patient had
exhibited the classic symptoms of dengue fever should have been: oxygen
inhalation, use of analgesic, and infusion of fluids or dextrose; and once the
patient had twice vomited fresh blood, the doctor should have ordered:
blood transfusion, monitoring of the patient every 30 minutes, hemostatic to
stop bleeding, and oxygen if there is difficulty in breathing. Dr. Casumpang
failed to measure up to these standards. The evidence strongly suggests that
he ordered a transfusion of platelet concentrate instead of blood transfusion.
The tourniquet test was only conducted after Edmer’s second episode of
bleeding, and the medical management (as reflected in the records) did not
include antibiotic therapy and complete physical examination.
Same; Same; Same; Same; While attending and resident physicians
share the collective responsibility to deliver safe and appropriate care to the
patients, it is the attending physician who assumes the principal
responsibility of patient care.—The attending physician, on the other hand,
is primarily responsible for managing the resident’s exercise of duties.
While attending and resident physicians share the collective responsibility to
deliver safe and appropriate care to the patients, it is the attending physician
who assumes the principal responsibility of patient care. Because he/she
exercises a supervisory role over the resident, and is ultimately responsible
for the diagnosis and treatment of the patient, the standards applicable to
and the liability of the resident for medical malpractice is theoretically less
than that of the attending physician. These relative burdens and distinctions,
however, do not translate to immunity from the legal duty of care for
residents, or from the responsibility arising from their own negligent act.
Same; Same; Same; Same; Expert Witnesses; The competence of an
expert witness is a matter for the trial court to decide upon in the exercise of
its discretion.—The competence of an expert witness is a matter for the trial
court to decide upon in the exercise of its discretion. The test of
qualification is necessarily a relative one, depending

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  upon the subject matter of the investigation, and the fitness of the
expert witness. In our jurisdiction, the criterion remains to be the expert
witness’ special knowledge experience and practical training that
qualify him/her to explain highly technical medical matters to the
Court.
Same; Same; Same; Same; Same; United States (US) jurisprudence on
medical malpractice demonstrated the trial courts’ wide latitude of
discretion in allowing a specialist from another field to testify against a
defendant specialist.—A close scrutiny of Ramos v. Court of Appeals, 321
SCRA 584 (1999), and Cereno v. Court of Appeals, 682 SCRA 18 (2012),
reveals that the Court primarily based the witnesses’ disqualification to
testify as an expert on their incapacity to shed light on the standard of care
that must be observed by the defendant-physicians. That the expert
witnesses’ specialties do not match the physicians’ practice area only
constituted, at most, one of the considerations that should not be taken out
of context. After all, the sole function of a medical expert witness,
regardless of his/her specialty, is to afford assistance to the courts on
medical matters, and to explain the medical facts in issue. Furthermore,
there was no reasonable indication in Ramos and Cereno that the expert
witnesses possess a sufficient familiarity with the standard of care
applicable to the physicians’ specialties. US jurisprudence on medical
malpractice demonstrated the trial courts’ wide latitude of discretion in
allowing a specialist from another field to testify against a defendant
specialist.
Same; Same; Same; Same; Same; Although he specializes in pathology,
it was established during trial that he had attended not less than thirty (30)
seminars held by the Pediatric Society, had exposure in pediatrics, had been
practicing medicine for sixteen (16) years, and had handled not less than
fifty (50) dengue-related cases.—In the case and the facts before us, we find
that Dr. Jaudian is competent to testify on the standard of care in dengue
fever cases. Although he specializes in pathology, it was established during
trial that he had attended not less than 30 seminars held by the Pediatric
Society, had exposure in pediatrics, had been practicing medicine for 16
years, and had handled not less than 50 dengue related cases. As a licensed
medical practitioner specializing in pathology, who had practical and
relevant exposure in pediatrics and dengue-related cases, we are convinced
that Dr. Jaudian demonstrated sufficient familiarity with the standard of care
to be applied in dengue fever cases. Furthermore,

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we agree that he possesses knowledge and experience sufficient to

qualify him to speak with authority on the subject.
Same; Same; Same; Same; Dr. Casumpang failed to timely diagnose
Edmer with dengue fever despite the presence of its characteristic
symptoms; and as a consequence of the delayed diagnosis, he also failed to
promptly manage Edmer’s illness.—Dr. Casumpang failed to timely
diagnose Edmer with dengue fever despite the presence of its characteristic
symptoms; and as a consequence of the delayed diagnosis, he 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 care and management needed for dengue
fever, the risk of complications or even death, could have been substantially
reduced. Furthermore, medical literature on dengue shows that early
diagnosis and management of dengue is critical in reducing the risk of
complications and avoiding further spread of the virus. That Edmer later
died of “Hypovolemic Shock/hemorrhagic shock,” “Dengue Hemorrhagic
Fever Stage IV,” a severe and fatal form of dengue fever, established the
causal link between Dr. Casumpang’s negligence and the injury.
Labor Law; Employer-Employee Relationship; Independent
Contractors; Based on the records, no evidence exists showing that San
Juan de Dios Hospital (SJDH) exercised any degree of control over the
means, methods of procedure and manner by which the petitioning doctors
conducted and performed their medical profession. SJDH did not control
their diagnosis and treatment; In these lights, the petitioning doctors were
not employees of SJDH, but were mere independent contractors.—In
determining whether an employer-employee relationship exists between the
parties, the following elements must be present: (1) selection and
engagement of services; (2) payment of wages; (3) the power to hire and
fire; and (4) the power to control not only the end to be achieved, but the
means to be used in reaching such an end. Control, which is the most crucial
among the elements, is not present in this case. Based on the records, no
evidence exists showing that SJDH exercised any degree of control over the
means, methods of procedure and manner by which the petitioning doctors
conducted and performed their medical profession. SJDH did not control
their diagnosis and treatment. Likewise, no evidence was presented to show
that SJDH monitored,

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supervised, or directed the petitioning doctors in the treatment and

management of Edmer’s case. In these lights, the petitioning doctors were
not employees of SJDH, but were mere independent contractors.
Same; Same; Same; As a rule, hospitals are not liable for the
negligence of its independent contractors.—Despite the absence of
employer-employee relationship between SJDH and the petitioning doctors,
SJDH is not free from liability. As a rule, hospitals are not liable for the
negligence of its independent contractors. However, it may be found liable
if the physician or independent contractor acts as an ostensible agent of the
hospital. This exception is also known as the “doctrine of apparent
authority.”
Civil Law; Hospitals; Vicarious Liability; A hospital can be held
vicariously liable for the negligent acts of a physician (or an independent
contractor) providing care at the hospital if the plaintiff can prove these two
(2) factors: first, the hospital’s manifestations; and second, the patient’s
reliance.—A hospital can be held vicariously liable for the negligent acts of
a physician (or an independent contractor) providing care at the hospital if
the plaintiff can prove these two factors: first, the hospital’s manifestations;
and second, the patient’s reliance.
Same; Quasi-Delicts; Medical Malpractice; Health Care Plans; 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.—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.
 PETITIONS for review on certiorari of the decision and
resolution of the Court of Appeals.

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Casumpang vs. Cortejo

The facts are stated in the opinion of the Court.

  Arturo D. Magdaong for Noel Casumpang.
  Palabrica & Palabrica for Nelson Cortejo.
  Romulo, Mabanta, Buenaventura, Sayoc & De Los Angeles for
San Juan de Dios Hospital.
  Chavez, Miranda, Aseoche Law Offices for Dr. Ruby Sanga-
Miranda.

 
BRION, J.:
 
We resolve the three (3) consolidated petitions for review on
certiorari1 involving medical negligence, commonly assailing the
October 29, 2004 decision2 and the January 12, 2006 resolution3 of
the Court of Appeals (CA) in C.A.-G.R. CV No. 56400. This CA
decision affirmed in toto the ruling of the Regional Trial Court
(RTC), Branch 134, Makati City.
The RTC awarded Nelson Cortejo (respondent) damages in the
total amount of P595,000.00, for the wrongful death of his son
allegedly due to the medical negligence of the petitioning doctors
and the hospital.
 
Factual Antecedents
 
The common factual antecedents are briefly summarized below.
On April 22, 1988, at about 11:30 in the morning, Mrs. Jesusa
Cortejo brought her 11-year-old son, Edmer Cortejo (Edmer), to the
Emergency Room of the San Juan de Dios

_______________

1  Under Rule 45 of the Rules of Court.

2   Rollo (G.R. No. 171127), pp. 19-32, penned by Associate Justice Vicente Q.
Roxas, and concurred in by Associate Justices Salvador J. Valdez, Jr. and Juan Q.
Enriquez, Jr.
3  Id., at pp. 34-38.

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Casumpang vs. Cortejo

Hospital (SJDH) because of difficulty in breathing, chest pain,

stomach pain, and fever.4
Dr. Ramoncito Livelo (Dr. Livelo) initially attended to and
examined Edmer. In her testimony, Mrs. Cortejo narrated that in the
morning of April 20, 1988, Edmer had developed a slight fever that
lasted for one day; a few hours upon discovery, she brought Edmer
to their family doctor; and two hours after administering
medications, Edmer’s fever had subsided.5
After taking Edmer’s medical history, Dr. Livelo took his 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 blood was
also taken for testing, typing, and for purposes of administering
antibiotics. Afterwards, Dr. Livelo gave Edmer an antibiotic
medication to lessen his fever and to loosen his phlegm.
Mrs. Cortejo did not know any doctor at SJDH. She used 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 also
accredited with Fortune Care.8
At 5:30 in the afternoon of the same day, Dr. Casumpang for the
first time examined Edmer in his room. Using only a stethoscope, he
confirmed the initial diagnosis of “Bronchopneumonia.”9
At that moment, Mrs. Cortejo recalled entertaining doubts on the
doctor’s diagnosis. She immediately advised Dr.

_______________

4   TSN, Jesusa Cortejo, November 27, 1990, pp. 2-3; TSN, Ramoncito Livelo,
February 16, 1993, pp. 5-6. (per Rollo [G.R. No. 171228], pp. 106-107)
5  TSN, May 2, 1991, pp. 12-16.
6  TSN, Dr. Ramoncito Livelo, February 16, 1993, pp. 5-6.
7  Id.
8  TSN, Jesusa Cortejo, November 27, 1990, pp. 5-7.
9  Id., at p. 7.

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390 SUPREME COURT REPORTS ANNOTATED

Casumpang vs. Cortejo
 Casumpang that Edmer had a high fever, and had no colds or
cough10 but Dr. Casumpang merely told her that her son’s “blood
pressure is just being active,”11 and remarked that “that’s the usual
bronchopneumonia, no colds, no phlegm.”12
Dr. Casumpang next visited and examined Edmer at 9:00 in the
morning the following day.13 Still suspicious about his son’s illness,
Mrs. Cortejo again called Dr. Casumpang’s attention and stated that
Edmer had a fever, throat irritation, as well as chest and stomach
pain. Mrs. Cortejo also alerted Dr. Casumpang about the traces of
blood in Edmer’s sputum. Despite these pieces of information,
however, Dr. Casumpang simply nodded, inquired if Edmer has an
asthma, and reassured Mrs. Cortejo that Edmer’s illness is
bronchopneumonia.14
At around 11:30 in the morning of April 23, 1988, Edmer
vomited “phlegm with blood streak”15 prompting the respondent
(Edmer’s father) to request for a doctor at the nurses’ station.16
Forty-five minutes later, Dr. Ruby Sanga-Miranda (Dr. Miranda),
one of the resident physicians of SJDH, arrived. She claimed that
although aware that Edmer had vomited “phlegm with blood streak,”
she failed to examine the blood specimen because the respondent
washed it away. She then advised the respondent to preserve the
specimen for examination.
Thereafter, Dr. Miranda conducted a physical checkup covering
Edmer’s head, eyes, nose, throat, lungs, skin and abdo-

_______________

10  Id., at pp. 4-5.

11  Id., at p. 14.
12  Id., at p. 8.
13  Id.
14  Id., at pp. 5-7.
15  More of coffee ground material.
16  TSN, Nelson Cortejo, July 16, 1991, pp. 6-8. Nelson Cortejo testified that his
son vomited a brown liquid and particles that look like dead blood.

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men; and found that Edmer had a low-grade non-continuing

fever, and rashes that were not typical of dengue fever.17 Her
medical findings state:
 the patient’s rapid breathing and then the lung showed sibilant and the
patient’s nose is flaring which is a sign that the patient is in respiratory
distress; the abdomen has negative finding; the patient has low grade fever
and not continuing; and the rashes in the patient’s skin were not “Herman’s
Rash” and not typical of dengue fever.18

 
At 3:00 in the afternoon, Edmer once again vomited blood. Upon
seeing Dr. Miranda, the respondent showed her Edmer’s blood
specimen, and reported that Edmer had complained of severe
stomach pain and difficulty in moving his right leg.19
Dr. Miranda then examined Edmer’s “sputum with blood” and
noted that he was bleeding. Suspecting that he could be afflicted
with dengue, she inserted a plastic tube in his nose, drained the
liquid from his stomach with ice cold normal saline solution, and
gave an instruction not to pull out the tube, or give the patient any
oral medication.
Dr. Miranda thereafter conducted a tourniquet test, which turned
out to be negative.20 She likewise ordered the monitoring of the
patient’s blood pressure and some blood tests. Edmer’s blood
pressure was later found to be normal.21
At 4:40 in the afternoon, Dr. Miranda called up Dr. Casumpang
at his clinic and told him about Edmer’s condition.22 Upon being
informed, Dr. Casumpang ordered several proce-

_______________

17  Id., at p. 10.
18  TSN, Ruby Sanga-Miranda, June 8, 1988, pp. 13-19.
19  TSN, Nelson Cortejo, July 16, 1991, p. 12.
20  Id., at pp. 11-13.
21  Id.
22  TSN, Ruby Sanga-Miranda, June 10, 1993, pp. 35-36.

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392 SUPREME COURT REPORTS ANNOTATED

Casumpang vs. Cortejo

dures done including: hematocrit, hemoglobin, blood typing,

blood transfusion and tourniquet tests.
The blood test results came at about 6:00 in the evening.
Dr. Miranda advised Edmer’s parents that the blood test results
showed that Edmer was suffering from “Dengue Hemorrhagic
Fever.” One hour later, Dr. Casumpang arrived at Edmer’s room and
he recommended his transfer to the Intensive Care Unit (ICU), to
which the respondent consented. Since the ICU was then full, Dr.
Casumpang suggested to the respondent that they hire a private
nurse. The respondent, however, insisted on transferring his son to
Makati Medical Center.
After the respondent had signed the waiver, Dr. Casumpang, for
the last time, checked Edmer’s condition, found that his blood
pressure was stable, and noted that he was “comfortable.” The
respondent requested for an ambulance but he was informed that the
driver was nowhere to be found. This prompted him to hire a private
ambulance that cost him P600.00.23
At 12:00 midnight, Edmer, accompanied by his parents and by
Dr. Casumpang, was transferred to Makati Medical Center.
Dr. Casumpang immediately gave the attending physician the
patient’s clinical history and laboratory exam results. Upon
examination, the attending physician diagnosed “Dengue Fever
Stage IV” that was already in its irreversible stage.
Edmer died at 4:00 in the morning of April 24, 1988.24 His Death
Certificate indicated the cause of death as “Hypovolemic
Shock/hemorrhagic shock”; “Dengue Hemorrhagic Fever Stage IV.”
Believing that Edmer’s death was caused by the negligent and
erroneous diagnosis of his doctors, the respondent insti-

_______________

23  TSN, Nelson Cortejo, July 16, 1991, p. 20.

24  RTC Records, p. 211.

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tuted an action for damages against SJDH, and its attending

physicians: Dr. Casumpang and Dr. Miranda (collectively referred to
as the “petitioners”) before the RTC of Makati City.
 
The Ruling of the Regional Trial Court
 
In a decision25 dated May 30, 1997, the RTC ruled in favor of the
respondent, and awarded actual and moral damages, plus attorney’s
fees and costs.
In ruling that the petitioning doctors were negligent, the RTC
found untenable the petitioning doctors’ contention that Edmer’s
initial symptoms did not indicate dengue fever. It faulted them for
heavily relying on the chest x-ray result and for not considering the
other manifestations that Edmer’s parents had relayed. It held that in
diagnosing and treating an illness, the physician’s conduct should be
judged not only by what he/she saw and knew, but also by what
he/she could have reasonably seen and known. It also observed that
based on Edmer’s signs and symptoms, his medical history and
physical examination, and also the information that the petitioning
doctors gathered from his family members, dengue fever was a
reasonably foreseeable illness; yet, the petitioning doctors failed to
take a second look, much less, consider these indicators of dengue.
The trial court also found that aside from their self-serving
testimonies, the petitioning doctors did not present other evidence to
prove that they exercised the proper medical attention in diagnosing
and treating the patient, leading it to conclude that they were guilty
of negligence.
The RTC also held SJDH solidarily liable with the petitioning
doctors for damages based on the following findings of facts: first,
Dr. Casumpang, as consultant, is an ostensible agent of SJDH
because before the hospital engaged his medical services, it
scrutinized and determined his fitness,

_______________

25  CA Rollo, pp. 535-551.

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394 SUPREME COURT REPORTS ANNOTATED

Casumpang vs. Cortejo

qualifications, and competence as a medical practitioner; and

second, Dr. Miranda, as resident physician, is an employee of SJDH
because like Dr. Casumpang, the hospital, through its screening
committee, scrutinized and determined her qualifications, fitness,
and competence before engaging her services; the hospital also
exercised control over her work.
The dispositive portion of the decision reads:

WHEREFORE, judgment is hereby rendered in favor of the plaintiff and

against the defendants, ordering the latter to pay solidarily and severally
plaintiff the following:
(1) Moral damages in the amount of P500,000.00;
(2) Costs of burial and funeral in the amount of P45,000.00;
(3) Attorney’s fees of P50,000.00; and
(4) Cost of this suit.
SO ORDERED.

 
 The petitioners appealed the decision to the CA.
 
The Ruling of the Court of Appeals
 
In its decision dated October 29, 2004, the CA affirmed in toto
the RTC’s ruling, finding that SJDH and its attending physicians
failed to exercise the minimum medical care, attention, and
treatment expected of an ordinary doctor under like circumstances.
The CA found the petitioning doctors’ failure to read even the
most basic signs of “dengue fever” expected of an ordinary doctor as
medical negligence. The CA also considered the petitioning doctors’
testimonies as self-serving, noting that they presented no other
evidence to prove that they exercised due diligence in diagnosing
Edmer’s illness.

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The CA likewise found Dr. Rodolfo Jaudian’s (Dr. Jaudian)

testimony admissible. It gave credence to his opinion26 that: (1)
given the exhibited symptoms of the patient, dengue fever should
definitely be considered, and bronchopneumonia could be
reasonably ruled out; and (2) dengue fever could have been detected
earlier than 7:30 in the evening of April 23, 1988 because the
symptoms were already evident; and agreed with the RTC that the
petitioning doctors should not have solely relied on the chest x-ray
result, as it was not conclusive.
On SJDH’s solidary liability, the CA ruled that the hospital’s
liability is based on Article 2180 of the Civil Code. The CA opined
that the control which the hospital exercises over its consultants, the
hospital’s power to hire and terminate their services, all fulfill the
employer-employee relationship requirement under Article 2180.
Lastly, the CA held that SJDH failed to adduce evidence showing
that it exercised the diligence of a good father of a family in the
hiring and the supervision of its physicians.

_______________

26  “[If] the patient is admitted for chest pain, abdominal pain, and difficulty of
breathing, dengue fever will definitely be considered”; “if the patient expectorated
coffee ground, and with the presence of bleeding, it is a clear case of dengue fever,
bronchopneumonia could be reasonably ruled out”; “if the patient complained of
rapid breathing, chest and stomach pain, the management should be oxygen
inhalation, analgesic, and infuse liquids or dextrose”; “if the patient had
expectorated fresh blood twice already and thrombocytopenia has occurred,
management should be blood transfusion, monitoring every 30 minutes, give
hemostatic to stop bleeding, and oxygen if there is difficulty in breathing”; “where the
platelet count drops to 47,000, dengue fever is foremost in physician’s mind, and the
management should be fresh blood infusion and supportive measures like oxygen and
inhalation”; “that if presented with symptoms, tourniquet test and management is the
proper treatment of this disease, and that it is possible that dengue fever could be
detected earlier than 7:30 PM of April 23, 1988 because the symptoms were
physically noted even by the parents and hospital personnel due to bleeding coupled
with history of fever.”

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The petitioners separately moved to reconsider the CA decision,

but the CA denied their motion in its resolution of January 12, 2006;
hence, the present consolidated petitions pursuant to Rule 45 of the
Rules of Court.
 
The Petitions
 
    I. Dr. Casumpang’s Position (G.R. No. 171127)
 
Dr. Casumpang contends that he gave his patient medical
treatment and care to the best of his abilities, and within the proper
standard of care required from physicians under similar
circumstances. He claims that his initial diagnosis of
bronchopneumonia was supported by the chest x-ray result.
Dr. Casumpang also contends that dengue fever occurs only after
several days of confinement. He alleged that when he had suspected
that Edmer might be suffering from dengue fever, he immediately
attended and treated him.
Dr. Casumpang likewise raised serious doubts on Dr. Jaudian’s
credibility, arguing that the CA erred in appreciating his testimony
as an expert witness since he lacked the necessary training, skills,
and experience as a specialist in dengue fever cases.
 
II. Dr. Miranda’s Position (G.R. No. 171217)
 
In her petition, Dr. Miranda faults the CA for holding her
responsible for Edmer’s wrong diagnosis, stressing that the function
of making the diagnosis and undertaking the medical treatment
devolved upon Dr. Casumpang, the doctor assigned to Edmer, and
who confirmed “bronchopneumonia.”
Dr. Miranda also alleged that she exercised prudence in
performing her duties as a physician, underscoring that it was her
professional intervention that led to the correct diagnosis of
“Dengue Hemorrhagic Fever.” Furthermore, Edmer’s Complete
Blood Count (CBC) showed leukopenia and an increase in balance
as shown by the differential count, demon-

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Casumpang vs. Cortejo

strating that Edmer’s infection, more or less, is of bacterial and

not viral in nature.
Dr. Miranda as well argued that there is no causal relation
between the alleged erroneous diagnosis and medication for
“Bronchopneumonia,” and Edmer’s death due to “Dengue
Hemorrhagic Fever.”
Lastly, she claimed that Dr. Jaudian is not a qualified expert
witness since he never presented any evidence of formal residency
training and fellowship status in Pediatrics.
 
III. SJDH’s Position (G.R. No. 171228)
 
SJDH, on the other hand, disclaims liability by asserting that Dr.
Casumpang and Dr. Miranda are mere independent contractors and
“consultants” (not employees) of the hospital. SJDH alleges that
since it did not exercise control or supervision over the consultants’
exercise of medical profession, there is no employer-employee
relationship between them, and consequently, Article 2180 of the
Civil Code does not apply.
SJDH likewise anchored the absence of employer-employee
relationship on the following circumstances: (1) SJDH does not hire
consultants; it only grants them privileges to admit patients in the
hospital through accreditation; (2) SJDH does not pay the
consultants wages similar to an ordinary employee; (3) the
consultants earn their own professional fees directly from their
patients; SJDH does not fire or terminate their services; and (4)
SJDH does not control or interfere with the manner and the means
the consultants use in the treatment of their patients. It merely
provides them with adequate space in exchange for rental payment.
Furthermore, SJDH claims that the CA erroneously applied the
control test when it treated the hospital’s practice of accrediting
consultants as an exercise of control. It explained that the control
contemplated by law is that which the employer exercises over the:
(i) end result; and the (ii) manner

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Casumpang vs. Cortejo

and means to be used to reach this end, and not any kind of
control, however significant, in accrediting the consultants.
SJDH moreover contends that even if the petitioning doctors are
considered employees and not merely consultants of the hospital,
SJDH cannot still be held solidarily liable under Article 2180 of the
Civil Code because it observed the diligence of a good father of a
family in their selection and supervision as shown by the following:
(1) the adequate measures that the hospital undertakes to ascertain
the petitioning doctors’ qualifications and medical competence; and
(2) the documentary evidence that the petitioning doctors presented
to prove their competence in the field of pediatrics.27
SJDH likewise faults the CA for ruling that the petitioning
doctors are its agents, claiming that this theory, aside from being
inconsistent with the CA’s finding of employment relationship, is
unfounded because: first, the petitioning doctors are independent
contractors, not agents of SJDH; and second, as a medical
institution, SJDH cannot practice medicine, much more, extend its
personality to physicians to practice medicine on its behalf.
Lastly, SJDH maintains that the petitioning doctors arrived at an
intelligently deduced and correct diagnosis. It claimed that based on
Edmer’s signs and symptoms at the time of admission (i.e., one day
fever,28 bacterial infection,29

_______________

27  As to Dr. Casumpang: i. Certification of Residency in Pediatrics; ii. Certificate

of Award certifying that he was considered to be the Most Outstanding Resident
Physician in the Department of Pediatrics; and iii. Certificate of recognition as a
Diplomate issued by the Philippine Pediatrics Society.
As to Dr. Miranda: i. Board Examination Certificate showing that she passed the
board examination; ii. Certification of Completion of Residency Training; and iii.
Certificate of recognition as a Diplomate in Pediatrics. (per Rollo [G.R. No. 171228],
pp. 42-43)
28  As stated by Dr. Miranda, and as SJDH claims, dengue manifests as a high
grade fever that is continuous for two (2) to seven

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Casumpang vs. Cortejo

and lack of hemorrhagic manifestations),30 there was no

reasonable indication yet that he was suffering from dengue fever,
and accordingly, their failure to diagnose dengue fever, does not
constitute negligence on their part.
 
The Case for the Respondent
 
In his comment, the respondent submits that the issues the
petitioners raised are mainly factual in nature, which a petition for
review on certiorari under Rule 45 of the Rules of Courts does not
allow.
In any case, he contends that the petitioning doctors were
negligent in conducting their medical examination and diagnosis
based on the following: (1) the petitioning doctors failed to timely
diagnose Edmer’s correct illness due to their nonobservance of the
proper and acceptable standard of medical examination; (2) the
petitioning doctors’ medical examination was not comprehensive, as
they were always in a rush; and (3) the petitioning doctors employed
a guessing game in diagnosing bronchopneumonia.
The respondent also alleges that there is a causal connection
between the petitioning doctors’ negligence and Edmer’s untimely
death, warranting the claim for damages.

_______________

(7) days. In this case, the petitioner doctors were presented with a patient with a
clinical history of one day fever. (id., at pp. 56-57)
29   In its petition, SJDH claimed that as opposed to Edmer’s white blood cell
(WBC) profile indicating a bacterial infection, dengue fever is caused not by a
bacterium, but by a virus. (id.)
30  SJDH substantiated its claim that there were no indications of dengue fever yet
at the time of Edmer’s admission by claiming that the latter was not
hemoconcentrated and did not have thrombocytopenia. It also claimed that Edmer
had no hemorrhagic manifestations at the time of his admission and until the
following day. (id., at pp. 56-58)

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400 SUPREME COURT REPORTS ANNOTATED

Casumpang vs. Cortejo
 The respondent, too, asserted that SJDH is also negligent because
it was not equipped with proper paging system, has no
bronchoscope, and its doctors are not proportionate to the number of
its patients. He also pointed out that out of the seven resident
physicians in the hospital, only two resident physicians were doing
rounds at the time of his son’s confinement.
 
The Issues
 
The case presents to us the following issues:
1. Whether or not the petitioning doctors had committed
“inexcusable lack of precaution” in diagnosing and in treating the
patient;
2. Whether or not the petitioner hospital is solidarily liable with
the petitioning doctors;
3. Whether or not there is a causal connection between the
petitioners’ negligent act/omission and the patient’s resulting death;
and
4. Whether or not the lower courts erred in considering Dr.
Rodolfo Tabangcora Jaudian as an expert witness.
 
Our Ruling
 
We find the petition partly meritorious.
 
A Petition for Review on Certiorari under Rule 45 of the Rules of
Court is Limited to Questions of Law
 
The settled rule is that the Court’s jurisdiction in a petition for
review on certiorari under Rule 45 of the Rules of Court is limited
only to the review of pure questions of law. It is not the Court’s
function to inquire on the veracity of the appellate

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court’s factual findings and conclusions; this Court is not a trier

of facts.31
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 when the
doubt arises as to the truth or falsity of the alleged facts.32
These consolidated petitions before us involve mixed questions
of fact and law. As a rule, we do not resolve questions of fact.
However, in determining the legal question of whether the
respondent is entitled to claim damages under Article 2176 of the
Civil Code for the petitioners’ alleged medical malpractice, the
determination of the factual issues — i.e., whether the petitioning
doctors were grossly negligent in diagnosing the patient’s illness,
whether there is causal relation between the petitioners’
act/omission and the patient’s resulting death, and whether Dr.
Jaudian is qualified as an expert witness — must necessarily be
resolved. We resolve these factual questions solely for the purpose
of determining the legal issues raised.
 
Medical Malpractice Suit as a Specialized Area of Tort Law
 
The claim for damages is based on the petitioning doctors’
negligence in diagnosing and treating the deceased Edmer, the child
of the respondent. It is a medical malpractice suit, an action
available to victims to redress a wrong committed by 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 medical
practitioner or health care pro-

_______________

31   First Metro Investment Corporation v. Este Del Sol Mountain Reserve, Inc.,
420 Phil. 902, 914; 396 SCRA 99, 111 (2001).
32   Land Bank of the Philippines v. Yatco Agricultural Enterprises, G.R. No.
172551, January 15, 2014, 713 SCRA 370, 379.
33  Flores v. Pineda, 591 Phil. 699, 706; 571 SCRA 83, 91 (2008).

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402 SUPREME COURT REPORTS ANNOTATED

Casumpang vs. Cortejo

vider fails to meet the standards demanded by his profession, or

deviates from this standard, and causes injury to the patient.
To successfully pursue a medical malpractice suit, the plaintiff
(in this case, the deceased patient’s heir) must prove that the doctor
either failed to do what a reasonably prudent doctor would have
done, or did what a reasonably prudent doctor would not have done;
and the act or omission had caused injury to the patient.34 The
patient’s heir/s bears the burden of proving his/her cause of action.
 
The Elements of a Medical Malpractice Suit
 
 The elements of medical negligence are: (1) duty; (2) breach;
(3) injury; and (4) proximate causation.
Duty refers to the standard of behavior that imposes restrictions
on one’s conduct.35 It requires proof of professional relationship
between the physician and the patient. Without the professional
relationship, a physician owes no duty to the patient, and cannot
therefore incur any liability.
A physician-patient relationship is created when a patient
engages the services of a physician,36 and the latter accepts or agrees
to provide care to the patient.37 The establishment of this
relationship is consensual,38 and the acceptance by the physician
essential. The mere fact that an individual ap-

_______________

34  Garcia-Rueda v. Pascasio, 344 Phil. 323, 331; 278 SCRA 769, 778 (1997).
35  Martin, C.R.A., Law Relating to Medical Malpractice (2nd ed.), p. 361.
36  Lucas v. Tuaño, 604 Phil. 98, 121; 586 SCRA 173, 200 (2009).
37  61 Am Jur 2d §130 p. 247.
38  Findlay v. Board of Supervisors of Mohave County, 72 Ariz 58, 230 P2.d 526,
24 A.L.R.2d.

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proaches a physician and seeks diagnosis, advice or treatment

does not create the duty of care unless the physician agrees.39
The consent needed to create the relationship does not always
need to be express.40 In the absence of an express agreement, a
physician-patient relationship may be implied from the physician’s
affirmative action to diagnose and/or treat a patient, or in his
participation in such diagnosis and/or treatment.41 The usual
illustration would be the case of a patient who goes to a hospital or a
clinic, and is examined and treated by the doctor. In this case, we
can infer, based on the established and customary practice in the
medical community that a patient-physician relationship exists.
Once a physician-patient relationship is established, the legal
duty of care follows. The doctor accordingly becomes duty-bound to
use at least the same standard of care that a reasonably competent
doctor would use to treat a medical condition under similar
circumstances.
Breach of duty occurs when the doctor fails to comply with, or
improperly performs his duties under professional standards. This
determination is both factual and legal, and is specific to each
individual case.42
If the patient, as a result of the breach of duty, is injured in body
or in health, actionable malpractice is committed, entitling the
patient to damages.43

_______________

39   Basic Elements of the Legal System of Physician Liability for Negligent

Patient Injury in the United States With Comparisons to England and Canada, Frank
G. Feeley, Wendy K. Mariner, 4 February 2000,
http://dcc2.bumc.bu.edu/RussianLegalHealthReform/Project
Documents/n740.IIG.Bkgd.pdf.
40  Problems in Health Care Law, Robert Miller, Rebecca C. Hutton, 8th edition.
41  Kelley v. Middle Tennessee Emergency Physicians, 133 SW3d 587, 596 (Tenn
2004).
42  Basic Elements of the Legal System of Physician Liability, supra.
43  Supra note 33.

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Casumpang vs. Cortejo

To successfully claim damages, the patient must lastly prove the

causal relation between the negligence and the injury. This
connection must be direct, natural, and should be unbroken by any
intervening efficient causes. In other words, the negligence must be
the proximate cause of the injury.44 The injury or damage is
proximately caused by the physician’s negligence when it appears,
based on the evidence and the expert testimony, that the negligence
played an integral part in causing the injury or damage, and that the
injury or damage was either a direct result, or a reasonably probable
consequence of the physician’s negligence.45
 
a. The Relationship Between Dr. Casumpang and Edmer
 
In the present case, the physician-patient relationship between Dr.
Casumpang and Edmer was created when the latter’s parents sought
the medical services of Dr. Casumpang, and the latter knowingly
accepted Edmer as a patient. Dr. Casumpang’s acceptance is implied
from his affirmative examination, diagnosis and treatment of Edmer.
On the other hand, Edmer’s parents, on their son’s behalf,
manifested their consent by availing of the benefits of their health
care plan, and by accepting the hospital’s assigned doctor without
objections.
  
b. The Relationship Between Dr. Miranda and Edmer
 
With respect to Dr. Miranda, her professional relationship with
Edmer arose when she assumed the obligation to provide resident
supervision over the latter. As second year resident doctor tasked to
do rounds and assist other physicians, Dr. Miranda is deemed to
have agreed to the creation of physi-

_______________

44   Jarcia, Jr. v. People, G.R. No. 187926, February 15, 2012, 666 SCRA 336,
351-359.
45   Dissecting Philippine Law and Jurisprudence on Medical Malpractice,
Darwin P. Angeles, A Framework of Philippine Medical Malpractice Law, 85 PHIL.
L.J. 895, (2011).

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cian-patient relationship with the hospital’s patients when she

participated in the diagnosis and prescribed a course of treatment for
Edmer.
The undisputed evidence shows that Dr. Miranda examined
Edmer twice (at around 12:00 and 3:30 in the afternoon of April 23,
1988), and in both instances, she prescribed treatment and
participated in the diagnosis of Edmer’s medical condition. Her
affirmative acts amounted to her acceptance of the physician-patient
relationship, and incidentally, the legal duty of care that went with it.
In Jarcia, Jr. v. People of the Philippines,46 the Court found the
doctors who merely passed by and were requested to attend to the
patient, liable for medical malpractice. It held that a physician-
patient relationship was established when they examined the patient,
and later assured the mother that everything was fine.
In the US case of Mead v. Legacy Health System,47 the Court also
considered the rendering of an opinion in the course of the patient’s
care as the doctor’s assent to the physician-patient relationship. It
ruled that the relationship was formed because of the doctor’s
affirmative action.
 Likewise, in Wax v. Johnson,48 the court found that a physician-
patient relationship was formed between a physician who “contracts,
agrees, undertakes, or otherwise assumes” the obligation to provide
resident supervision at a teaching hospital, and the patient with
whom the doctor had no direct or indirect contract.
  
Standard of Care and Breach of Duty
 
A determination of whether or not the petitioning doctors met the
required standard of care involves a question of

_______________

46  Supra note 44.

47  231, Or App 451, 220 P3d 118 (Or 2009).
48  42 SW3d 168 (Tex App-Houston 1st Dist 2001).

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mixed fact and law; it is factual as medical negligence cases are

highly technical in nature, requiring the presentation of expert
witnesses to provide guidance to the court on matters clearly falling
within the domain of medical science, and legal, insofar as the
Court, after evaluating the expert testimonies, and guided by
medical literature, learned treatises, and its fund of common
knowledge, ultimately determines whether breach of duty took
place.
Whether or not Dr. Casumpang and Dr. Miranda committed a
breach of duty is to be measured by the yardstick of professional
standards observed by the other members of the medical profession
in good standing under similar circumstances.49 It is in this aspect of
medical malpractice that expert testimony is essential to establish
not only the professional standards observed in the medical
community, but also that the physician’s conduct in the treatment of
care falls below such standard.50
In the present case, expert testimony is crucial in determining
first, the standard medical examinations, tests, and procedures that
the attending physicians should have undertaken in the diagnosis
and treatment of dengue fever; and second, the dengue fever signs
and symptoms that the attending physicians should have noticed and
considered.
Both the RTC and the CA relied largely on Dr. Jaudian’s expert
testimony on dengue diagnosis and management to support their
finding that the petitioning doctors were guilty of breach of duty of
care.
Dr. Jaudian testified that Edmer’s rapid breathing, chest and
stomach pain, fever, and the presence of blood in his saliva are
classic symptoms of dengue fever. According to him,

_______________

49  Cruz v. Court of Appeals, 346 Phil. 872, 883; 282 SCRA 188, 200 (1997).
50  Solidum v. People, G.R. No. 192123, March 10, 2014, 718 SCRA 263.

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if the patient was admitted for chest pain, abdominal pain, and
difficulty in breathing coupled with fever, dengue fever should
definitely be considered;51 if the patient spits coffee ground with the
presence of blood, and the patient’s platelet count drops to 47,000, it
becomes a clear case of dengue fever, and bronchopneumonia can be
reasonably ruled out.52
Furthermore, the standard of care according to Dr. Jaudian is to
administer oxygen inhalation, analgesic, and fluid infusion or
dextrose.53 If the patient had twice vomited fresh blood and
thrombocytopenia has already occurred, the doctor should order
blood transfusion, monitoring of the patient every 30 minutes,
hemostatic to stop bleeding, and oxygen if there is difficulty in
breathing.54
We find that Dr. Casumpang, as Edmer’s attending
physician, did not act according to these standards and, hence,
was guilty of breach of duty. We do not find Dr. Miranda liable
for the reasons discussed below.
 
Dr. Casumpang’s Negligence
 
a. Negligence in the Diagnosis
 
At the trial, Dr. Casumpang declared that a doctor’s impression
regarding a patient’s illness is 90% based on the physical
examination, the information given by the patient or the latter’s
parents, and the patient’s medical history.55 He testified that he did
not consider either dengue fever or dengue hemorrhagic fever
because the patient’s history showed that Edmer had low breath and
voluntary submission, and

_______________

51  TSN, January 30, 1992, p. 11.

52  Id.
 53  Id., at p. 15.
54  Id.
55  Id., at p. 10.

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that he was up and about playing basketball.56 He based his

diagnosis of bronchopneumonia on the following observations:
“difficulty in breathing, clearing run nostril, harsh breath sound,
tight air, and sivilant sound.”57
It will be recalled that during Dr. Casumpang’s first and second
visits to Edmer, he already had knowledge of Edmer’s laboratory
test result (CBC), medical history, and symptoms (i.e., fever, rashes,
rapid breathing, chest and stomach pain, throat irritation, difficulty
in breathing, and traces of blood in the sputum). However, these
information did not lead Dr. Casumpang to the possibility that
Edmer could be suffering from either dengue fever, or dengue
hemorrhagic fever, as he clung to his diagnosis of
bronchopneumonia. This means that given the symptoms
exhibited, Dr. Casumpang already ruled out the possibility of other
diseases like dengue.
In other words, it was lost on Dr. Casumpang that the
characteristic symptoms of dengue (as Dr. Jaudian testified) are:
patient’s rapid breathing; chest and stomach pain; fever; and the
presence of blood in his saliva. All these manifestations were
present and known to Dr. Casumpang at the time of his first and
second visits to Edmer. While he noted some of these symptoms in
confirming bronchopneumonia, he did not seem to have considered
the patient’s other manifestations in ruling out dengue fever or
dengue hemorrhagic fever.58 To our mind, Dr. Casumpang
selectively appreciated some, and not all of the symptoms; worse, he
casually ignored the pieces of information that could have been
material in detecting dengue fever. This is evident from the
testimony of Mrs. Cortejo:

_______________

56  Id.
57  Id., at p. 8.
58  Id., at pp. 11-13.

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Casumpang vs. Cortejo

TSN, Mrs. Cortejo, November 27, 1990

Q: Now, when Dr. Casumpang visited your son for the first time at 5:30
p.m., what did he do, if any?
A: He examined my son by using stethoscope and after that, he
confirmed to me that my son was suffering from bronchopneumonia.
Q: After he confirmed that your son was suffering bronchopneumonia,
what did you say if any?
A: Again, I told Dr. Casumpang, how come it was
bronchopneumonia when my son has no cough or colds.
Q: What was the answer of Dr. Casumpang to your statement?
x x x x
A: And then, Dr. Casumpang answered “THAT’S THE USUAL
BRONCHOPNEUMONIA, NO COLDS, NO PHLEGM.”
Q: How long did Dr. Casumpang stay in your son’s room?
A: He stayed for a minute or 2.
x x x x
Q: When Dr. Casumpang arrived at 9:00 o’clock a.m. on April 23, what
did you tell him, if any?
x x x x
A: I told Dr. Casumpang… After examining my son using
stethoscope and nothing more, I told Dr. Casumpang about the traces of
blood in my son’s sputum and I told him what is all about and he has
throat irritation.
Q: What did he tell you?
A: He just nodded his head but he did not take the initiative of
looking at the throat of my son.

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Q: So what happened after that?

A: I also told Dr. Casumpang about his chest pain and also stomach
pain.
Q: So what did Dr. Casumpang do after you have narrated all these
complaints of your son?
A: Nothing. He also noticed the rapid breathing of my son and my
son was almost moving because of rapid breathing and he is swaying in
the bed.
Q: Do you know what action was taken by Dr. Casumpang when you
told him that your son is experiencing a rapid breathing?
 A: No action. He just asked me if my son has an asthma but I said
none.
Q: So how long did Dr. Casumpang stay and attended your son on
April 23?
A: More or less two (2) minutes then I followed him up to the door
and I repeated about the fever of my son.
Q: What did he tell you, if any, regarding that information you gave
him that your son had a fever?
A: He said, that is bronchopneumonia, it’s only being active now.
  [Emphasis supplied]

 
We also find it strange why Dr. Casumpang did not even bother
to check Edmer’s throat despite knowing that as early as 9:00 in the
morning of April 23, 1988, Edmer had blood streaks in his sputum.
Neither did Dr. Casumpang order confirmatory tests to confirm the
source of bleeding. The Physician’s Progress Notes59 stated: “Blood
streaks on phlegm can be due to bronchial irritation or congestion,”
which clearly showed that Dr. Casumpang merely assumed, without
con-

_______________

59  Rollo (G.R. No. 171228), pp. 263-265.

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firmatory physical examination, that bronchopneumonia caused

the bleeding.
Dr. Jaudian likewise opined that Dr. Casumpang’s medical
examination was not comprehensive enough to reasonably lead to a
correct diagnosis.60 Dr. Casumpang only used a stethoscope in
coming up with the diagnosis that Edmer was suffering from
bronchopneumonia; he never confirmed this finding with the use of a
bronchoscope. Furthermore, Dr. Casumpang based his diagnosis
largely on the chest x-ray result that is generally inconclusive.61
Significantly, it was only at around 5:00 in the afternoon of April
23, 1988 (after Edmer’s third episode of bleeding) that Dr.
Casumpang ordered the conduct of hematocrit, hemoglobin, blood
typing, blood transfusion and tourniquet tests. These tests came too
late, as proven by: (1) the blood test results that came at about 6:00
in the evening, confirming that Edmer’s illness had developed to
“Dengue Hemorrhagic Fever”; and (2) Dr. Jaudian’s testimony that
“dengue fever could have been detected earlier than 7:30 in the
evening of April 23, 1988 because the symptoms were already
evident.”62
In Spouses Flores v. Spouses Pineda,63 a case involving a
medical malpractice suit, the Court ruled that the petitioner doctors
were negligent because they failed to immediately order tests to
confirm the patient’s illness. Despite the doctors’ suspicion that the
patient could be suffering from diabetes, the former still proceeded
to the D&C operation. In that case, expert testimony showed that
tests should have been ordered immediately on admission to the
hospital in view of the symptoms presented. The Court held:

_______________

60  Rollo (G.R. No. 171127), p. 62.

61  Id., at pp. 64-65.
62  TSN, February 27, 1992, p. 8.
63  Supra note 33.

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When a patient exhibits symptoms typical of a particular disease, these

symptoms should, at the very least, alert the physician of the possibility that
the patient may be afflicted with the suspected disease.

 
The Court also ruled that reasonable prudence would have shown
that diabetes and its complications were foreseeable harm. However,
the petitioner doctors failed to take this into consideration and
proceeded with the D&C operation. Thus, the Court ruled that they
failed to comply with their duty to observe the standard of care to be
given to hyperglycemic/diabetic patients.
Similarly, in Jarcia,64 involving the negligence of the doctors in
failing to exercise reasonable prudence in ascertaining the extent of
the patient’s injuries, this Court declared that:

In failing to perform an extensive medical examination to determine

the extent of Roy Jr.’s injuries, Dr. Jarcia and Dr. Bastan were remiss of
their duties as members of the medical profession. Assuming for the sake
of argument that they did not have the capacity to make such thorough
evaluation at that stage, they should have referred the patient to another
doctor with sufficient training and experience instead of assuring him and
his mother that everything was all right. [Emphasis supplied]
  
Even assuming that Edmer’s symptoms completely coincided
with the diagnosis of bronchopneumonia (so that this diagnosis
could not be considered “wrong”), we still find Dr. Casumpang
guilty of negligence.
First, we emphasize that we do not decide the correctness of a
doctor’s diagnosis, or the accuracy of the medical findings and
treatment. Our duty in medical

_______________

64   Supra note 44. This is a criminal case for reckless imprudence resulting to
serious physical injuries filed against Dr. Jarcia, Dr. Bastan, and Dr. Pamittan.

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malpractice cases is to decide — based on the evidence adduced

and expert opinion presented — whether a breach of duty took
place.
Second, we clarify that a wrong diagnosis is not by itself
medical malpractice.65 Physicians are generally not liable for
damages resulting from a bona fide error of judgment. Nonetheless,
when the physician’s erroneous diagnosis was the result of negligent
conduct (e.g., neglect of medical history, failure to order the
appropriate tests, failure to recognize symptoms), it becomes an
evidence of medical malpractice.
Third, we also note that medicine is not an exact science;66 and
doctors, or even specialists, are not expected to give a 100%
accurate diagnosis in treating patients who come to their clinic for
consultations. Error is possible as the exercise of judgment is called
for in considering and reading the exhibited symptoms, the results of
tests, and in arriving at definitive conclusions. But in doing all these,
the doctor must have acted according to acceptable medical practice
standards.
In the present case, evidence on record established that in
confirming the diagnosis of bronchopneumonia, Dr. Casumpang
selectively appreciated some and not all of the symptoms presented,
and failed to promptly conduct the appropriate tests to confirm his
findings. In sum, Dr. Casumpang failed to timely detect dengue
fever, which failure, especially when reasonable prudence would
have shown that indications of dengue were evident and/or
foreseeable, constitutes negligence.
_______________

65   61 Am Jur 2d, 190; the question in professional malpractice suits is not

whether a physician had made a mistake but whether he or she used ordinary care.
66  22A Am Jur 2d, 570.

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a. Negligence in the Treatment and Management of Dengue

 
Apart from failing to promptly detect dengue fever, Dr.
Casumpang also failed to promptly undertake the proper medical
management needed for this disease.
As Dr. Jaudian opined, the standard medical procedure once the
patient had exhibited the classic symptoms of dengue fever should
have been: oxygen inhalation, use of analgesic, and infusion of fluids
or dextrose;67 and once the patient had twice vomited fresh blood,
the doctor should have ordered: blood transfusion, monitoring of the
patient every 30 minutes, hemostatic to stop bleeding, and oxygen if
there is difficulty in breathing.68
Dr. Casumpang failed to measure up to these standards. The
evidence strongly suggests that he ordered a transfusion of platelet
concentrate instead of blood transfusion. The tourniquet test was
only conducted after Edmer’s second episode of bleeding, and the
medical management (as reflected in the records) did not include
antibiotic therapy and complete physical examination.
Dr. Casumpang’s testimony states:

Q: Now, after entertaining — After considering that the patient Edmer

Cortero was already suffering from dengue hemorrhagic fever, what did you
do, if any?
A: We ordered close monitoring of the blood pressure, the cardiac
rate and respiratory rate of the patient.
Q: Now, was your instructions carried on?
A: Yes, sir.

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67  TSN, January 30, 1992, p. 15 (per Rollo [G.R. No. 171228], p. 82).
68  Id.

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Casumpang vs. Cortejo

Q: What was the blood pressure of the patient?

A: During those times, the blood pressure of the patient was even normal
during those times.
Q: How about the respiratory rate?
A: The respiratory rate was fast because the patient in the beginning
since admission had difficulty in breathing.
Q: Then, after that, what did you do with the patient? Doctor?
A: We transfused platelet concentrate and at the same time, we
monitor [sic] the patient.
Q: Then, who monitor [sic] the patient?
A: The pediatric resident on duty at that time.
Q: Now, what happened after that?
A: While monitoring the patient, all his vital signs were _____; his blood
pressure was normal so we continued with the supportive management at
that time.
Q: Now, after that?
A: In the evening of April 23, 1988, I stayed in the hospital and I was
informed by the pediatric resident on duty at around 11:15 in the evening
that the blood pressure of the patient went down to .60 palpatory.
Q: What did you do upon receipt of that information?
A: I immediately went up to the room of the patient and we changed
the IV fluid from the present fluid which was D5 0.3 sodium chloride to
lactated ringers solution.
Q: You mean to say you increased the dengue [sic] of the intervenus
[sic] fluid?
A: We changed the IV fluid because lactated ringers was necessary
to resume the volume and to bring back the blood pressure, to increase
the blood pressure. [Emphasis supplied]

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416 SUPREME COURT REPORTS ANNOTATED

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Although Dr. Casumpang presented the testimonies of Dr.

Rodolfo Jagonap and Dr. Ellewelyn Pasion (Dr. Pasion), Personnel
Officer and Medical Director of SJDH, respectively as well as the
testimonies of Dr. Livelo and Dr. Reyes (the radiologist who read
Edmer’s chest x-ray result), these witnesses failed to dispute the
standard of action that Dr. Jaudian established in his expert opinion.
We cannot consider them expert witnesses either for the sole reason
that they did not testify on the standard of care in dengue cases.69
 On the whole, after examining the totality of the adduced
evidence, we find that the lower courts correctly did not rely on Dr.
Casumpang’s claim that he exercised prudence and due diligence in
handling Edmer’s case. Aside from being self-serving, his claim is
not supported by competent evidence. As the lower courts did, we
rely on the uncontroverted fact that he failed, as a medical
professional, to observe the most prudent medical procedure under
the circumstances in diagnosing and treating Edmer.
 
Dr. Miranda is Not Liable for Negligence
 
In considering the case of Dr. Miranda, the junior resident
physician who was on-duty at the time of Edmer’s confinement, we
see the need to draw distinctions between the responsibilities and
corresponding liability of Dr. Casumpang, as the attending
physician, and that of Dr. Miranda.
In his testimony, Dr. Pasion declared that resident applicants are
generally doctors of medicine licensed to practice in the Philippines
and who would like to pursue a particular specialty.70 They are
usually the frontline doctors responsible for the first contact with the
patient. During the scope of the

_______________

69  These witnesses were presented as ordinary witnesses.

70  TSN, January 26, 1993, p. 6.

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residency program,71 resident physicians (or “residents”)72

function under the supervision of attending physicians73 or of the
hospital’s teaching staff. Under this arrangement, residents operate
merely as subordinates who usually defer to the attending physician
on the decision to be made and on the action to be taken.
The attending physician, on the other hand, is primarily
responsible for managing the resident’s exercise of duties. While
attending and resident physicians share the collective responsibility
to deliver safe and appropriate care to the patients,74 it is the
attending physician who assumes the principal responsibility of
patient care.75 Because he/she exercises a supervisory role over the
resident, and is ultimately responsible for the diagnosis and
treatment of the patient, the standards applicable to and the liability
of the resident for medical malpractice is theoretically less than that
of the attending physician. These relative burdens and distinctions,
however, do not translate to immunity from the legal duty of care for
residents,76 or from the responsibility arising from their own
negligent act.

_______________

71   Residency is a period of advanced medical training and education that

normally follows graduation from medical school and licensing to practice medicine
and that consists of a specialty in a hospital and in its outpatient department and
instruction from specialists on the hospital staff. Merriam-Webster’s Medical
Dictionary, p. 648.
72   A physician serving a residency; Merriam-Webster’s Medical Dictionary, p.
648.
73  A physician or surgeon on the staff of a hospital, regularly visiting and treating
patients, and often supervising students, fellows, and the house staff; Merriam-
Webster’s Medical Dictionary, p. 58.
74   Professional Liability Issues in Graduate Medical Institution,
www.Ncbi.nlm.nih.gov/pubmed/15339896.
75  755 ILCS 35/2(a); Illinois Jurisprudence, Health Law.
76  Mercil v. Mathers, No. C3-93-140, 1994 WL 1114 (Minn Ct App Jan. 4, 1994).

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418 SUPREME COURT REPORTS ANNOTATED

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In Jenkins v. Clark,77 the Ohio Court of Appeals held that the

applicable standard of care in medical malpractice cases involving
first year residents was that of a reasonably prudent physician and
not that of interns. According to Jenkins:

It is clear that the standard of care required of physicians is not an

individualized one but of physicians in general in the community. In order to
establish medical malpractice, it must be shown by a preponderance of the
evidence that a physician did some particular thing or things that a physician
or surgeon of ordinary skill, care and diligence would not have done under
like or similar conditions or circumstances, or that he failed or omitted to do
some particular thing or things that a physician or surgeon of ordinary skill,
care and diligence would have done under like or similar conditions or
circumstances, and that the inquiry complained of was the direct result of
such doing or failing to do such thing or things.
We note that the standard of instruction given by the court was indeed a
proper one. It clearly informed the jury that the medical care required is
that of reasonably careful physicians or hospital emergency room
operators, not of interns or residents. [Emphasis supplied]
  
 A decade later, Centman v. Cobb,78 affirmed the Jenkins ruling
and held that interns and first year residents are “practitioners of
medicine required to exercise the same standard of care applicable
to physicians with unlimited licenses to practice.” The Indiana Court
held that although a first year resident practices under a temporary
medical permit, he/she impliedly contracts that he/she has the
reasonable and ordinary qualifications of her profession and that
he/she will exercise reasonable skill, diligence, and care in treating
the patient.

_______________

77  7 Ohio App. 3d 93, 101 (1982).

78  581 N.E.2d 1286 (Ind Ct App 1991).

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We find that Dr. Miranda was not independently negligent.

Although she had greater patient exposure, and was subject to the
same standard of care applicable to attending physicians, we believe
that a finding of negligence should also depend on several
competing factors, among them, her authority to make her own
diagnosis, the degree of supervision of the attending physician over
her, and the shared responsibility between her and the attending
physicians.
In this case, before Dr. Miranda attended to Edmer, both Dr.
Livelo and Dr. Casumpang had diagnosed Edmer with
bronchopneumonia. In her testimony, Dr. Miranda admitted that she
had been briefed about Edmer’s condition, his medical history, and
initial diagnosis;79 and based on these pieces of information, she
confirmed the finding of bronchopneumonia.
Dr. Miranda likewise duly reported to Dr. Casumpang, who
admitted receiving updates regarding Edmer’s condition.80 There is
also evidence supporting Dr. Miranda’s claim that she extended
diligent care to Edmer. In fact, when she suspected — during
Edmer’s second episode of bleeding — that Edmer could be
suffering from dengue fever, she wasted no time in conducting the
necessary tests, and promptly notified Dr. Casumpang about the
incident. Indubitably, her medical assistance led to the finding of
dengue fever.
We note however, that during Edmer’s second episode of
bleeding,81 Dr. Miranda failed to immediately examine and note the
cause of the blood specimen. Like Dr. Casumpang, she merely
assumed that the blood in Edmer’s phlegm was caused by
bronchopneumonia. Her testimony states:

TSN, June 8, 1993:

Q: Let us get this clear, you said that the father told you the patient
cocked [sic] out phlegm.
A: With blood streak.

_______________

79  TSN, June 8, 1993, pp. 11-13.

80  TSN, March 2, 1993, pp. 23, 31-33; April 1, 1993, p. 6.
81  At 11:30 in the morning of April 23, 1988.

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420 SUPREME COURT REPORTS ANNOTATED

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Q: Now, you stated specimen, were you not able to examine the
specimen?
A: No, sir, I did not because according to the father he wash [sic] his
hands.
x x x x
Q: Now, from your knowledge, what does that indicate if the patient
expels a phlegm and blood streak?
A: If a patient cocked [sic] out phlegm then the specimen could have
come from the lung alone.82 [Emphasis supplied]
x x x x
TSN, June 17, 1993:
Q: Now, in the first meeting you had, when that was relayed to you by
the father that Edmer Cortejo had coughed out blood, what medical action
did you take?
A: I examined the patient and I thought that, that coughed out phlegm
was a product of bronchopneumonia.
x x x x
Q: So what examination did you specifically conduct to see that there
was no internal bleeding?
A: At that time I did not do anything to determine the cause of
coughing of the blood because I presumed that it was a mucous (sic)
produced by bronchopneumonia, and besides the patient did not even
show any signs of any other illness at that time.83

 
 Based on her statements we find that Dr. Miranda was not
entirely faultless. Nevertheless, her failure to discern the import
of Edmer’s second bleeding does not necessarily amount to
negligence as the respondent himself admitted

_______________

82  TSN, June 8, 1993, p. 16.

83  TSN, June 17, 1993, pp. 27-28.

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that Dr. Miranda failed to examine the blood specimen because

he washed it away. In addition, considering the diagnosis previously
made by two doctors, and the uncontroverted fact that the burden of
final diagnosis pertains to the attending physician (in this case, Dr.
Casumpang), we believe that Dr. Miranda’s error was merely an
honest mistake of judgment influenced in no small measure by her
status in the hospital hierarchy; hence, she should not be held liable
for medical negligence.
 
Dr. Jaudian’s Professional Competence and Credibility
 
One of the critical issues the petitioners raised in the proceedings
before the lower court and before this Court was Dr. Jaudian’s
competence and credibility as an expert witness. The petitioners
tried to discredit his expert testimony on the ground that he lacked
the proper training and fellowship status in pediatrics.
 
Criteria in Qualifying as an Expert Witness
 
The competence of an expert witness is a matter for the trial court
to decide upon in the exercise of its discretion. The test of
qualification is necessarily a relative one, depending upon the
subject matter of the investigation, and the fitness of the expert
witness.84 In our jurisdiction, the criterion remains to be the expert
witness’ special knowledge experience and practical training
that qualify him/her to explain highly technical medical matters
to the Court.
In Ramos v. Court of Appeals,85 the Court found the expert
witness, who is a pulmonologist, not qualified to testify on the field
of anesthesiology. Similarly, in Cereno v. Court of Ap-
_______________

84  Tomasa Vda. de Jacob v. Court of Appeals, 371 Phil. 693, 709; 312 SCRA 772,
780 (1999).
85  378 Phil. 1198; 321 SCRA 584 (1999).

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422 SUPREME COURT REPORTS ANNOTATED

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peals,86 a 2012 case involving medical negligence, the Court

excluded the testimony of an expert witness whose specialty was
anesthesiology, and concluded that an anesthesiologist cannot be
considered an expert in the field of surgery or even in surgical
practices and diagnosis.
Interestingly in this case, Dr. Jaudian, the expert witness was
admittedly not a pediatrician but a practicing physician who
specializes in pathology.87 He likewise does not possess any formal
residency training in pediatrics. Nonetheless, both the lower courts
found his knowledge acquired through study and practical
experience sufficient to advance an expert opinion on dengue-related
cases.
We agree with the lower courts.
A close scrutiny of Ramos and Cereno reveals that the Court
primarily based the witnesses’ disqualification to testify as an expert
on their incapacity to shed light on the standard of care that must be
observed by the defendant-physicians. That the expert witnesses’
specialties do not match the physicians’ practice area only
constituted, at most, one of the considerations that should not be
taken out of context. After all, the sole function of a medical expert
witness, regardless of his/her specialty, is to afford assistance to the
courts on medical matters, and to explain the medical facts in issue.
Furthermore, there was no reasonable indication in Ramos and
Cereno that the expert witnesses possess a sufficient familiarity with
the standard of care applicable to the physicians’ specialties.
US jurisprudence on medical malpractice demonstrated the trial
courts’ wide latitude of discretion in allowing a specialist from
another field to testify against a defendant specialist.

_______________

86  G.R. No. 167366, September 26, 2012, 682 SCRA 18.

87   Pathology is the study of diseases, their essential nature, causes, and
development, and the structural and functional changes produced by them. (Webster’s
Third New International Dictionary, p. 1655)
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In Brown v. Sims,88 a neurosurgeon was found competent to give

expert testimony regarding a gynecologist’s standard of pre-surgical
care. In that case, the court held that since negligence was not
predicated on the gynecologist’s negligent performance of the
operation, but primarily on the claim that the preoperative histories
and physicals were inadequate, the neurosurgeon was competent to
testify as an expert.
Frost v. Mayo Clinic,89 also allowed an orthopedic surgeon to
testify against a neurologist in a medical malpractice action. The
court considered that the orthopedic surgeon’s opinion on the
“immediate need for decompression” need not come from a
specialist in neurosurgery. The court held that:

It is well-established that “the testimony of a qualified medical doctor

cannot be excluded simply because he is not a specialist x x x.” The matter
of “x x x training and specialization of the witness goes to the weight rather
than admissibility x x x.”
x x x x
It did not appear to the court that a medical doctor had to be a specialist
in neurosurgery to express the opinions permitted to be expressed by
plaintiffs’ doctors, e.g., the immediate need for a decompression in the light
of certain neurological deficits in a post-laminectomy patient. As stated
above, there was no issue as to the proper execution of the neurosurgery.
The medical testimony supported plaintiffs’ theory of negligence and
causation. (Citations omitted)

 
In another case,90 the court declared that it is the specialist’s
knowledge of the requisite subject matter, rather than his/her
specialty that determines his/her qualification to testify.

_______________

88  538 So. 2d 901 (Fla. Dist. Ct. App. 1989).

89  304 F. Supp. 285 (1969).
90  McLean v. Hunter, 495 So. 2d 1298 (1986).

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424 SUPREME COURT REPORTS ANNOTATED

 Casumpang vs. Cortejo

  Also in Evans v. Ohanesian,91 the court set a guideline in

qualifying an expert witness:

To qualify a witness as a medical expert, it must be shown that the

witness (1) has the required professional knowledge, learning and skill
of the subject under inquiry sufficient to qualify him to speak with
authority on the subject; and (2) is familiar with the standard required
of a physician under similar circumstances; where a witness has
disclosed sufficient knowledge of the subject to entitle his opinion to go to
the jury, the question of the degree of his knowledge goes more to the
weight of the evidence than to its admissibility.
x x x x
Nor is it critical whether a medical expert is a general practitioner or a
specialist so long as he exhibits knowledge of the subject. Where a duly
licensed and practicing physician has gained knowledge of the standard
of care applicable to a specialty in which he is not directly engaged but
as to which he has an opinion based on education, experience,
observation, or association wit that specialty, his opinion is competent.
(Emphasis supplied)

 
Finally, Brown v. Mladineo92 adhered to the principle that the
witness’ familiarity, and not the classification by title or specialty,
which should control issues regarding the expert witness’
qualifications:

_______________

91   39 Cal. App. 3d 121, 112 Cal. Rptr. 236 (1974). This is a dental medical
malpractice suit brought against a practitioner of general dentistry.
92   504 So. 2d. 1201 (1987). The issue involved in this case is whether the
testimony of a pathologist-general surgeon may be admitted as expert testimony on
the medical negligence of an OB-gynecologist.

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The general rule as to expert testimony in medical malpractice actions is

that “a specialist in a particular branch within a profession will not be
required.” Most courts allow a doctor to testify if they are satisfied of his
familiarity with the standards of a specialty, though he may not practice the
specialty himself. One court explained that “it is the scope of the witness’
knowledge and not the artificial classification by title that should govern the
threshold question of admissibility.” (Citations omitted)

 
Application to the Present Case
 
In the case and the facts before us, we find that Dr. Jaudian is
competent to testify on the standard of care in dengue fever cases.
Although he specializes in pathology, it was established during
trial that he had attended not less than 30 seminars held by the
Pediatric Society, had exposure in pediatrics, had been practicing
medicine for 16 years, and had handled not less than 50 dengue-
related cases.
As a licensed medical practitioner specializing in pathology, who
had practical and relevant exposure in pediatrics and dengue related
cases, we are convinced that Dr. Jaudian demonstrated sufficient
familiarity with the standard of care to be applied in dengue fever
cases. Furthermore, we agree that he possesses knowledge and
experience sufficient to qualify him to speak with authority on the
subject.
 
The Causation Between Dr. Casumpang’s Negligent Act/Omission,
and the Patient’s Resulting Death was Adequately Proven
 
Dr. Jaudian’s testimony strongly suggests that due to Dr.
Casumpang’s failure to timely diagnose Edmer with dengue, the
latter was not immediately given the proper treatment. In fact, even
after Dr. Casumpang had discovered Edmer’s real

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426 SUPREME COURT REPORTS ANNOTATED

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illness, he still failed to promptly perform the standard medical

procedure. We agree with these findings.
As the respondent had pointed out, dengue fever, if left untreated,
could be a life threatening disease. As in any fatal diseases, it
requires immediate medical attention.93 With the correct and timely
diagnosis, coupled with the proper medical management, dengue
fever is not a life-threatening disease and could easily be cured.94
Furthermore, as Dr. Jaudian testified, with adequate intensive
care, the mortality rate of dengue fever should fall to less than 2%.
Hence, the survival of the patient is directly related to early and
proper management of the illness.95
 To reiterate, Dr. Casumpang failed to timely diagnose Edmer
with dengue fever despite the presence of its characteristic
symptoms; and as a consequence of the delayed diagnosis, he 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 care and
management needed for dengue fever, the risk of complications or
even death, could have been substantially reduced.
Furthermore, medical literature on dengue shows that early
diagnosis and management of dengue is critical in reducing the risk
of complications and avoiding further spread of the virus.96 That
Edmer later died of “Hypovolemic Shock/hemorrhagic shock,”
“Dengue Hemorrhagic Fever Stage IV,” a severe and fatal form of
dengue fever, established the causal link between Dr. Casumpang’s
negligence and the injury.

_______________

93  Rollo (G.R. No. 171127), p. 128.

94  Id., at p. 62.
95  TSN, February 27, 1992, p. 12.
96   WHO, Dengue and Severe Dengue; http://www.who.int/media
centre/factsheets/fs117/en/.

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Based on these considerations, we rule that the respondent

successfully proved the element of causation.
 
Liability of SJDH
 
We now discuss the liability of the hospital.
The respondent submits that SJDH should not only be held
vicariously liable for the petitioning doctors’ negligence but also for
its own negligence. He claims that SJDH fell short of its duty of
providing its patients with the necessary facilities and equipment as
shown by the following circumstances:
 
(a) SJDH was not equipped with proper paging system;
(b) the number of its doctors is not proportionate to the number
of patients;
(c) SJDH was not equipped with a bronchoscope;
 (d) when Edmer’s oxygen was removed, the medical staff did not
immediately provide him with portable oxygen;
(e) when Edmer was about to be transferred to another hospital,
SJDH’s was not ready and had no driver; and
(f) despite Edmer’s critical condition, there was no doctor
attending to him from 5:30 p.m. of April 22, to 9:00 a.m. of April
23, 1988.
 
SJDH on the other hand disclaims liability by claiming that the
petitioning doctors are not its employees but are mere consultants
and independent contractors.
We affirm the hospital’s liability not on the basis of Article 2180
of the Civil Code, but on the basis of the doctrine of apparent
authority or agency by estoppel.

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428 SUPREME COURT REPORTS ANNOTATED

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There is No Employer-Employee Relationship Between SJDH and

the Petitioning Doctors
 
In determining whether an employer-employee relationship exists
between the parties, the following elements must be present: (1)
selection and engagement of services; (2) payment of wages; (3) the
power to hire and fire; and (4) the power to control not only the end
to be achieved, but the means to be used in reaching such an end.97
Control, which is the most crucial among the elements, is not
present in this case.
Based on the records, no evidence exists showing that SJDH
exercised any degree of control over the means, methods of
procedure and manner by which the petitioning doctors conducted
and performed their medical profession. SJDH did not control their
diagnosis and treatment. Likewise, no evidence was presented to
show that SJDH monitored, supervised, or directed the petitioning
doctors in the treatment and management of Edmer’s case. In these
lights, the petitioning doctors were not employees of SJDH, but
were mere independent contractors.
 
SJDH is Solidarily Liable based on the Principle of Agency or
Doctrine of Apparent Authority
 
Despite the absence of employer-employee relationship between
SJDH and the petitioning doctors, SJDH is not free from liability.98
 As a rule, hospitals are not liable for the negligence of its
independent contractors. However, it may be found liable if

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97  Ramos v. Court of Appeals, supra note 85.

98  Nogales v. Capitol Medical Center, 540 Phil. 225, 245-247; 511 SCRA 204,
228 (2006).

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the physician or independent contractor acts as an ostensible

agent of the hospital. This exception is also known as the “doctrine
of apparent authority.”99
The US case of Gilbert v. Sycamore Municipal Hospital100
abrogated the hospitals’ immunity to vicarious liability of
independent contractor physicians. In that case, the Illinois Supreme
Court held that under the doctrine of apparent authority, hospitals
could be found vicariously liable for the negligence of an
independent contractor:

Therefore, we hold that, under the doctrine of apparent authority, a

hospital can be held vicariously liable for the negligent acts of a physician
providing care at the hospital, regardless of whether the physician is an
independent contractor, unless the patient knows, or should have known,
that the physician is an independent contractor. The elements of the action
have been set out as follows:
For a hospital to be liable under the doctrine of apparent authority, a
plaintiff must show that: (1) the hospital, or its agent, acted in a manner
that would lead a reasonable person to conclude that the individual who
was alleged to be negligent was an employee or agent of the hospital; (2)
where the acts of the agent create the appearance of authority, the
plaintiff must also prove that the hospital had knowledge of and
acquiesced in them; and (3) the plaintiff acted in reliance upon the
conduct of the hospital or its agent, consistent with ordinary care and
prudence. (Emphasis supplied)

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99   Id.
100  156 Ill. 2d 511, 622 N.E. 2d 788 (1993).

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430 SUPREME COURT REPORTS ANNOTATED
Casumpang vs. Cortejo

The doctrine was applied in Nogales v. Capitol Medical Center101

where this Court, through the ponencia of Associate Justice Antonio
T. Carpio, discussed the two factors in determining hospital liability
as follows:

The first factor focuses on the hospital’s manifestations and is sometimes

described as an inquiry whether the hospital acted in a manner which would
lead a reasonable person to conclude that the individual who was alleged to
be negligent was an employee or agent of the hospital. In this regard, the
hospital need not make express representations to the patient that the
treating physician is an employee of the hospital; rather a representation
may be general and implied.
x x x x
The second factor focuses on the patient’s reliance. It is sometimes
characterized as an inquiry on whether the plaintiff acted in reliance upon
the conduct of the hospital or its agent, consistent with ordinary care and
prudence. (Citation omitted)

 
In sum, a hospital can be held vicariously liable for the negligent
acts of a physician (or an independent contractor) providing care at
the hospital if the plaintiff can prove these two factors: first, the
hospital’s manifestations; and second, the patient’s reliance.
 
a. Hospital’s manifestations
 
It involves an inquiry on whether the hospital acted in a manner
that would lead a reasonable person to conclude that the individual
alleged to be negligent was an employee or agent of the hospital. As
pointed out in Nogales, the hospital need not make express
representations to the patient that the

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101  Supra note 98 at p. 246; pp. 223, 226.

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Casumpang vs. Cortejo
 physician or independent contractor is an employee of the
hospital; representation may be general and implied.102
  In Pamperin v. Trinity Memorial Hospital,103 questions were
raised on “what acts by the hospital or its agent are sufficient to lead
a reasonable person to conclude that the individual was an agent of
the hospital.” In ruling that the hospital’s manifestations can be
proven without the express representation by the hospital, the court
relied on several cases from other jurisdictions, and held that:
 
(1) the hospital, by providing emergency room care and by
failing to advise patients that they were being treated by the
hospital’s agent and not its employee, has created the appearance of
agency; and
(2) patients entering the hospital through the emergency room,
could properly assume that the treating doctors and staff of the
hospital were acting on its behalf.
 
In this case, the court considered the act of the hospital of
holding itself out as provider of complete medical care, and
considered the hospital to have impliedly created the appearance of
authority.
 
b. Patient’s reliance
 
It involves an inquiry on whether the plaintiff acted in reliance on
the conduct of the hospital or its agent, consistent with ordinary care
and prudence.104
In Pamperin, the court held that the important consideration in
determining the patient’s reliance is: whether the plaintiff is seeking
care from the hospital itself or whether the

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102  Id.
103  144 Wis. 2d 188, 207, 423 N.W. 2d. 848, 855 (1988).
104  PSI v. Court of Appeals, 568 Phil. 158, 166-167; 544 SCRA 170, 180 (2008),
citing Diggs v. Novant Health, Inc., 628 S.E.2d 851 (2006) and Hylton v. Koontz, 138
N.C. App. 629 (2000).

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432 SUPREME COURT REPORTS ANNOTATED

Casumpang vs. Cortejo

plaintiff is looking to the hospital merely as a place for his/her

personal physician to provide medical care.105
 Thus, this requirement is deemed satisfied if the plaintiff can
prove that he/she relied upon the hospital to provide care and
treatment, rather than upon a specific physician. In this case, we
shall limit the determination of the hospital’s apparent authority to
Dr. Casumpang, in view of our finding that Dr. Miranda is not liable
for negligence.
 
SJDH Clothed Dr. Casumpang with Apparent Authority
 
SJDH impliedly held out and clothed Dr. Casumpang with
apparent authority leading the respondent to believe that he is an
employee or agent of the hospital.
Based on the records, the respondent relied on SJDH rather than
upon Dr. Casumpang, to care and treat his son Edmer. His testimony
during trial showed that he and his wife did not know any doctors at
SJDH; they also did not know that Dr. Casumpang was an
independent contractor. They brought their son to SJDH for
diagnosis because of their family doctor’s referral. The referral did
not specifically point to Dr. Casumpang or even to Dr. Miranda, but
to SJDH.
Significantly, the respondent had relied on SJDH’s representation
of Dr. Casumpang’s authority. To recall, when Mrs. Cortejo
presented her Fortune Care card, she was initially referred 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.

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105  Pamperin v. Trinity Memorial Hospital, supra note 103.

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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 and the Resolution dated
January 12, 2006 in C.A.-G.R. CV No. 56400.
SO ORDERED.

Carpio (Chairperson), Villarama, Jr.,** Mendoza and Leonen,

JJ., concur.

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* * Designated as additional member, in lieu of Associate Justice Mariano C. Del

Castillo, per Raffle dated February 9, 2015.

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434 SUPREME COURT REPORTS ANNOTATED

Casumpang vs. Cortejo

Consolidated petitions partly granted, finding of liability as to

Dr. Ruby Sanga-Miranda set aside. Judgment and resolution
affirmed.

Notes.—Medical malpractice or, more appropriately, medical

negligence, is that type of claim which a victim has available to him
or her to redress a wrong committed by a medical professional
which has caused bodily harm. (Dela Torre vs. Imbuido, 736 SCRA
655 [2014])
It is settled that a physician’s duty to his patient relates to his
exercise of the degree of care, skill and diligence which physicians
 in the same general neighborhood, and in the same general line of
practice, ordinarily possess and exercise in like cases. (Id.)
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