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478

SUPREME COURT REPORTS ANNOTATED


Professional Services, Inc. vs. Agana
*

G.R. No. 126297. January 31, 2007.

PROFESSIONAL SERVICES, INC., petitioner,


NATIVIDAD and ENRIQUE AGANA, respondents.

vs.

G.R. No. 126467. January 31, 2007.

NATIVIDAD and ENRIQUE AGANA, respondents.


NATIVIDAD (Substituted by her children MARCELINO
AGANA III, ENRIQUE AGANA, JR., EMMA AGANA
ANDAYA, JESUS AGANA, and RAYMUND AGANA) and
ENRIQUE AGANA, petitioners, vs. JUAN FUENTES,
respondent.
*

G.R. No. 127590. January 31, 2007.

MIGUEL AMPIL, petitioner, vs. NATIVIDAD AGANA and


ENRIQUE AGANA, respondents.
_______________
*

FIRST DIVISION.
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Professional Services, Inc. vs. Agana


Civil Law Damages Negligence The leaving of sponges or
other foreign substances in the wound after the incision has been
closed is at least prima facie negligence by the operating surgeon.
An operation requiring the placing of sponges in the incision is
not complete until the sponges are properly removed, and it is
settled that the leaving of sponges or other foreign substances in
the wound after the incision has been closed is at least prima facie
negligence by the operating surgeon. To put it simply, such act is

considered so inconsistent with due care as to raise an inference


of negligence. There are even legions of authorities to the effect
that such act is negligence per se.
Same Same Same To the mind of the Court, what was
initially an act of negligence by Dr. Ampil has ripened into a
deliberate wrongful act of deceiving his patient.Here, Dr. Ampil
did not inform Natividad about the missing two pieces of gauze.
Worse, he even misled her that the pain she was experiencing was
the ordinary consequence of her operation. Had he been more
candid, Natividad could have taken the immediate and
appropriate medical remedy to remove the gauzes from her body.
To our mind, what was initially an act of negligence by Dr. Ampil
has ripened into a deliberate wrongful act of deceiving his patient.
Same Same Same Doctrine of Res Ipsa Loquitur Requisites
for the Applicability of the Doctrine.Literally, res ipsa loquitur
means the thing speaks for itself. It is the rule that the fact of
the occurrence of an injury, taken with the surrounding
circumstances, may permit an inference or raise a presumption of
negligence, or make out a plaintiffs prima facie case, and present
a question of fact for defendant to meet with an explanation.
Stated differently, where the thing which caused the injury,
without the fault of the injured, is under the exclusive control of
the defendant and the injury is such that it should not have
occurred if he, having such control used proper care, it affords
reasonable evidence, in the absence of explanation that the injury
arose from the defendants want of care, and the burden of proof is
shifted to him to establish that he has observed due care and
diligence. From the foregoing statements of the rule, the
requisites for the applicability of the doctrine of res ipsa loquitur
are: (1) the occurrence of an injury (2) the thing which caused the
injury was under the control and management of the defendant
(3) the occurrence was such that in the ordinary course of things,
would
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SUPREME COURT REPORTS ANNOTATED


Professional Services, Inc. vs. Agana

not have happened if those who had control or management used


proper care and (4) the absence of explanation by the defendant.
Of the foregoing requisites, the most instrumental is the control
and management of the thing which caused the injury.

Same Same Same Same Res ipsa loquitur is not a rule of


substantive law, hence, does not per se create or constitute an
independent or separate ground of liability, being a mere
evidentiary rule.In this jurisdiction, res ipsa loquitur is not a
rule of substantive law, hence, does not per se create or constitute
an independent or separate ground of liability, being a mere
evidentiary rule. In other words, mere invocation and application
of the doctrine does not dispense with the requirement of proof of
negligence. Here, the negligence was proven to have been
committed by Dr. Ampil and not by Dr. Fuentes.
Same Same Same Professionals are considered personally
liable for the fault or negligence they commit in the discharge of
their duties and their employer cannot be held liable for such fault
or negligence.A prominent civilist commented that professionals
engaged by an employer, such as physicians, dentists, and
pharmacists, are not employees under this article because the
manner in which they perform their work is not within the control
of the latter (employer). In other words, professionals are
considered personally liable for the fault or negligence they commit
in the discharge of their duties, and their employer cannot be held
liable for such fault or negligence. In the context of the present
case, a hospital cannot be held liable for the fault or negligence of
a physician or surgeon in the treatment or operation of patients.
Same Same Same In this jurisdiction, the nature of the
relationship between the hospital and the physicians is rendered
inconsequential in view of the pronouncement in Ramos vs. Court
of Appeals, 321 SCRA 584 (1999), that for purposes of
apportioning responsibility in medical negligence cases, an
employeremployee relationship in effect exists between hospitals
and their attending and visiting physicians.In our shores, the
nature of the relationship between the hospital and the
physicians is rendered inconsequential in view of our categorical
pronouncement in Ramos v. Court of Appeals, 321 SCRA 584
(1999), that for purposes of apportioning responsibility in
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Professional Services, Inc. vs. Agana

medical negligence cases, an employeremployee relationship in


effect exists between hospitals and their attending and visiting
physicians.

SameSame Same PSIs liability is also anchored upon the


agency principle of apparent authority or agency by estoppel and
the doctrine of corporate negligence.But the Ramos
pronouncement is not our only basis in sustaining PSIs liability.
Its liability is also anchored upon the agency principle of apparent
authority or agency by estoppel and the doctrine of corporate
negligence which have gained acceptance in the determination of
a hospitals liability for negligent acts of health professionals. The
present case serves as a perfect platform to test the applicability
of these doctrines, thus, enriching our jurisprudence. Apparent
authority, or what is sometimes referred to as the holding out
theory, or doctrine of ostensible agency or agency by estoppel, has
its origin from the law of agency. It imposes liability, not as the
result of the reality of a contractual relationship, but rather
because of the actions of a principal or an employer in somehow
misleading the public into believing that the relationship or the
authority exists. The concept is essentially one of estoppel and has
been explained in this manner: The principal is bound by the acts
of his agent with the apparent authority which he knowingly
permits the agent to assume, or which he holds the agent out to
the public as possessing. The question in every case is whether
the principal has by his voluntary act placed the agent in such a
situation that a person of ordinary prudence, conversant with
business usages and the nature of the particular business, is
justified in presuming that such agent has authority to perform
the particular act in question.
Same Same Same In cases where it can be shown that a
hospital, by its actions, has held out a particular physician as its
agent and/or employee and that a patient has accepted treatment
from that physician in the reasonable belief that it is being
rendered in behalf of the hospital, then the hospital will be liable
for the physicians negligence.The applicability of apparent
authority in the field of hospital liability was upheld long time ago
in Irving v. Doctor Hospital of Lake Worth, Inc., 415 So. 2d 55
(1982). There, it was explicitly stated that there does not appear
to be any rational basis for excluding the concept of apparent
authority from the field of hospital liability. Thus, in cases where
it can be shown that a hospital, by its actions, has held out a
particular physician as its agent and/or employee and
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SUPREME COURT REPORTS ANNOTATED


Professional Services, Inc. vs. Agana

that a patient has accepted treatment from that physician in the


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

PETITION for review on certiorari of the decisions of the


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

SANDOVALGUTIERREZ, J.:
Hospitals, having undertaken one of mankinds most
important and delicate endeavors, must assume the grave

responsibility of pursuing it with appropriate care. The


care and service dispensed through this high trust,
however technical, complex and esoteric its character may
be, must meet standards of responsibility commensurate
with the undertaking to preserve and protect the health,
and indeed,
the very lives of those placed in the hospitals
1
keeping.
Assailed in these three consolidated petitions for2 review
on certiorari is the Court of Appeals Decision dated
September 6, 1996 in CAG.R. CV No. 42062 and CAG.R.3
SP No. 32198 affirming with modification the Decision
dated March 17, 1993 of the Regional Trial Court (RTC),
Branch 96, Quezon City in Civil Case No. Q43322 and
nullifying its Order dated September 21, 1993.
The facts, as culled from the records, are:
On April 4, 1984, Natividad Agana was rushed to the
Medical City General Hospital (Medical City Hospital)
because of difficulty of bowel movement and bloody anal
discharge. After a series of medical examinations, Dr.
Miguel Ampil, petitioner in G.R. No. 127590, diagnosed her
to be suffering from cancer of the sigmoid.
_______________
Beeck v. Tucson General Hospital, 500 P. 2d 1153 (1972), citing

Darling v. Charleston Community Memorial Hospital, 33 Ill. 2d 326, 211


N.E. 2d 253.
2

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

Supreme Court) and concurred in by Associate Justices Eugenio S.


Labitoria and Artemio G. Tuquero (both retired), Rollo, G.R. No. 126297,
pp. 3651 126467, pp. 2742 127590, pp. 2338.
3

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

Appeals), Rollo, G.R. No. 126647, pp. 6983.


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SUPREME COURT REPORTS ANNOTATED


Professional Services, Inc. vs. Agana
4

On April 11, 1984, Dr. Ampil, assisted by the medical staff


of the Medical City Hospital, performed an anterior
resection surgery on Natividad. He found that the
malignancy in her sigmoid area had spread on her left
ovary, necessitating the removal of certain portions of it.
Thus, Dr. Ampil obtained the consent of Natividads
husband, Enrique Agana, to permit Dr. Juan Fuentes,
respondent in G.R. No. 126467, to perform hysterectomy on
her.

After Dr. Fuentes had completed the hysterectomy, Dr.


Ampil took over, completed the operation and closed the
incision.
However, the operation appeared to be flawed. In the
corresponding Record of Operation dated April 11, 1984,
the attending nurses entered these remarks:
sponge count lacking 2
announced to surgeon searched (sic) done but to no
avail continue for closure.

On April 24, 1984, Natividad was released from the


hospital. Her hospital and medical bills, including the
doctors fees, amounted to P60,000.00.
After a couple of days, Natividad complained of
excruciating pain in her anal region. She consulted both
Dr. Ampil and Dr. Fuentes about it. They told her that the
pain was the natural consequence of the surgery. Dr. Ampil
then recommended that she consult an oncologist to
examine the cancerous nodes which were not removed
during the operation.
On May 9, 1984, Natividad, accompanied by her
husband, went to the United States to seek further
treatment. After four months of consultations and
laboratory examinations, Natividad was told she was free
of cancer. Hence, she was advised to return to the
Philippines.
_______________
4

The medical staff was composed of physicians, both residents and

interns, as well as nurses.


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Professional Services, Inc. vs. Agana

On August 31, 1984, Natividad flew back to the


Philippines, still suffering from pains. Two weeks
thereafter, her daughter found a piece of gauze protruding
from her vagina. Upon being informed about it, Dr. Ampil
proceeded to her house where he managed to extract by
hand a piece of gauze measuring 1.5 inches in width. He
then assured her that the pains would soon vanish.
Dr. Ampils assurance did not come true. Instead, the
pains intensified, prompting Natividad to seek treatment
at the Polymedic General Hospital. While confined there,

Dr. Ramon Gutierrez detected the presence of another


foreign object in her vaginaa foulsmelling gauze
measuring 1.5 inches in width which badly infected her
vaginal vault. A rectovaginal fistula had formed in her
reproductive organs which forced stool to excrete through
the vagina. Another surgical operation was needed to
remedy the damage. Thus, in October 1984, Natividad
underwent another surgery.
On November 12, 1984, Natividad and her husband filed
with the RTC, Branch 96, Quezon City a complaint for
damages against the Professional Services, Inc. (PSI),
owner of the Medical City Hospital, Dr. Ampil, and Dr.
Fuentes, docketed as Civil Case No. Q43322. They alleged
that the latter are liable for negligence for leaving two
pieces of gauze inside Natividads body and malpractice for
concealing their acts of negligence.
Meanwhile, Enrique Agana also filed with the
Professional
Regulation
Commission
(PRC)
an
administrative complaint for gross negligence and
malpractice against Dr. Ampil and Dr. Fuentes, docketed
as Administrative Case No. 1690. The PRC Board of
Medicine heard the case only with respect to Dr. Fuentes
because it failed to acquire jurisdiction over Dr. Ampil who
was then in the United States.
On February 16, 1986, pending the outcome of the above
cases, Natividad died and was duly substituted by her
abovenamed children (the Aganas).
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Professional Services, Inc. vs. Agana

On March 17, 1993, the RTC rendered its Decision in favor


of the Aganas, finding PSI, Dr. Ampil and Dr. Fuentes
liable for negligence and malpractice, the decretal part of
which reads:
WHEREFORE, judgment is hereby rendered for the plaintiffs
ordering the defendants PROFESSIONAL SERVICES, INC.,
DR. MIGUEL AMPIL and DR. JUAN FUENTES to pay to the
plaintiffs, jointly and severally, except in respect of the award for
exemplary damages and the interest thereon which are the
liabilities of defendants Dr. Ampil and Dr. Fuentes only, as
follows:
1. As actual damages, the following amounts:

The equivalent in Philippine Currency of the total of


a. US$19,900.00 at the rate of P21.60US$1.00, as
reimbursement of actual expenses incurred in the United
States of America
b. The sum of P4,800.00 as travel taxes of plaintiffs and their
physician daughter
c. The total sum of P45,802.50, representing the cost of
hospitalization at Polymedic Hospital, medical fees, and
cost of the saline solution
2. As moral damages, the sum of P2,000,000.00
3. As exemplary damages, the sum of P300,000.00
4. As attorneys fees, the sum of P250,000.00
5. Legal interest on items 1 (a), (b), and (c) 2 and 3
hereinabove, from date of filing of the complaint until full
payment and
6. Costs of suit.
SO ORDERED.

Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an


appeal to the Court of Appeals, docketed as CAG.R. CV
No. 42062.
Incidentally, on April 3, 1993, the Aganas filed with the
RTC a motion for a partial execution of its Decision, which
was granted in an Order dated May 11, 1993. Thereafter,
the sheriff levied upon certain properties of Dr. Ampil and
sold
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them for P451,275.00 and delivered the amount to the


Aganas.
Following their receipt of the money, the Aganas entered
into an agreement with PSI and Dr. Fuentes to indefinitely
suspend any further execution of the RTC Decision.
However, not long thereafter, the Aganas again filed a
motion for an alias writ of execution against the properties
of PSI and Dr. Fuentes. On September 21, 1993, the RTC
granted the motion and issued the corresponding writ,
prompting Dr. Fuentes to file with the Court of Appeals a
petition for certiorari and prohibition, with prayer for
preliminary injunction, docketed as CAG.R. SP No. 32198.
During its pendency, the Court of Appeals issued a
5

Resolution dated October 29, 1993 granting Dr. Fuentes

Resolution dated October 29, 1993 granting Dr. Fuentes


prayer for injunctive relief.
On January 24, 1994, CAG.R. SP No. 32198 was
consolidated with CAG.R. CV No. 42062.
Meanwhile, on January 23,
1995, the PRC Board of
6
Medicine rendered its Decision in Administrative Case No.
1690 dismissing the case against Dr. Fuentes. The Board
held that the prosecution failed to show that Dr. Fuentes
was the one who left the two pieces of gauze inside
Natividads body and that he concealed such fact from
Natividad.
_______________
5

The dispositive portion reads:

WHEREFORE, let a writ of preliminary injunction be issued upon petitioners


posting of bond in the amount of P20,000.00, ENJOINING public respondents
from implementing the questioned order dated September 21, 1993 and from
further taking any action in Civil Case No. Q43322 entitled Natividad G. Agana,
et al., plaintiffs, versus Professional Services, Inc., et al., defendants pending
resolution of the instant petition.
SO ORDERED. See Rollo, G.R. No. 126297, p. 42.
6

Rollo of G.R. No. 126467, pp. 8489.


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Professional Services, Inc. vs. Agana

On September 6, 1996, the Court of Appeals rendered its


Decision jointly disposing of CAG.R. CV No. 42062 and
CAG.R. SP No. 32198, thus:
WHEREFORE, except for the modification that the case against
defendantappellant Dr. Juan Fuentes is hereby DISMISSED,
and with the pronouncement that defendantappellant Dr. Miguel
Ampil is liable to reimburse defendantappellant Professional
Services, Inc., whatever amount the latter will pay or had paid
to the plaintiffsappellees, the decision appealed from is hereby
AFFIRMED and the instant appeal DISMISSED.
Concomitant with the above, the petition for certiorari and
prohibition filed by herein defendantappellant Dr. Juan Fuentes
in CAG.R. SP No. 32198 is hereby GRANTED and the
challenged order of the respondent judge dated September 21,
1993, as well as the alias writ of execution issued pursuant
thereto are hereby NULLIFIED and SET ASIDE. The bond
posted by the petitioner in connection with the writ of preliminary

injunction issued by this Court on November 29, 1993 is hereby


cancelled.
Costs against defendantsappellants Dr. Miguel Ampil and
Professional Services, Inc.
SO ORDERED.

Only Dr. Ampil filed a motion


for reconsideration, but it
7
was denied in a Resolution dated December 19, 1996.
Hence, the instant consolidated petitions.
In G.R. No. 126297, PSI alleged in its petition that the
Court of Appeals erred in holding that: (1) it is estopped
from raising the defense that Dr. Ampil is not its employee
(2) it is solidarily liable with Dr. Ampil and (3) it is not
entitled to its counterclaim against the Aganas. PSI
contends that Dr. Ampil is not its employee, but a mere
consultant or independent contractor. As such, he alone
should answer for his negligence.
_______________
7

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


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In G.R. No. 126467, the Aganas maintain that the Court of


Appeals erred in finding that Dr. Fuentes is not guilty of
negligence or medical malpractice, invoking the doctrine of
res ipsa loquitur. They contend that the pieces of gauze are
prima facie proofs that the operating surgeons have been
negligent.
Finally, in G.R. No. 127590, Dr. Ampil asserts that the
Court of Appeals erred in finding him liable for negligence
and malpractice sans evidence that he left the two pieces of
gauze in Natividads vagina. He pointed to other probable
causes, such as: (1) it was Dr. Fuentes who used gauzes in
performing the hysterectomy (2) the attending nurses
failure to properly count the gauzes used during surgery
and (3) the medical intervention of the American doctors
who examined Natividad in the United States of America.
For our resolution are these three vital issues: first,
whether the Court of Appeals erred in holding Dr. Ampil
liable for negligence and malpractice second, whether the
Court of Appeals erred in absolving Dr. Fuentes of any
liability and third, whether PSI may be held solidarily
liable for the negligence of Dr. Ampil.

IG.R. No. 127590


Whether the Court of Appeals Erred in Holding Dr.
Ampil Liable for Negligence and Malpractice.
Dr. Ampil, in an attempt to absolve himself, gears the
Courts attention to other possible causes of Natividads
detriment. He argues that the Court should not discount
either of the following possibilities: first, Dr. Fuentes left
the gauzes in Natividads body after performing
hysterectomy second, the attending nurses erred in
counting the gauzes and third, the American doctors were
the ones who placed the gauzes in Natividads body.
Dr. Ampils arguments are purely conjectural and
without basis. Records show that he did not present any
evidence to prove that the American doctors were the ones
who put or left
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Professional Services, Inc. vs. Agana

the gauzes in Natividads body. Neither did he submit


evidence to rebut the correctness of the record of operation,
particularly the number of gauzes used. As to the alleged
negligence of Dr. Fuentes, we are mindful that Dr. Ampil
examined his (Dr. Fuentes) work and found it in order.
The glaring truth is that all the major circumstances,
taken together, as specified by the Court of Appeals,
directly point to Dr. Ampil as the negligent party, thus:
First, it is not disputed that the surgeons used gauzes as sponges
to control the bleeding of the patient during the surgical
operation.
Second, immediately after the operation, the nurses who
assisted in the surgery noted in their report that the sponge
count (was) lacking 2 that such anomaly was announced to
surgeon and that a search was done but to no avail
prompting Dr. Ampil to continue for closure x x x.
Third, after the operation, two (2) gauzes were extracted from
the same spot of the body of Mrs. Agana where the surgery was
performed.

An operation requiring the placing of sponges in the


incision is not complete until the sponges are properly
removed, and it is settled that the leaving of sponges or
other foreign substances in the wound after the incision

has been closed is8 at least prima facie negligence by the


operating surgeon. To put it simply, such act is considered
so inconsistent with due care as to raise an inference of
negligence. There are even legions of9 authorities to the
effect that such act is negligence per se.
_______________
8

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

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

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

(C.C.A.) 172 F. 191 Reeves v. Lutz, 179 Mo. App. 61, 162 S.W. 280
Rayburn v. Day, 126 Or. 135, 68 P. 1002, 59 A.L.R. 1062 Wynne v.
Harvey, 96 Wash. 379, 165 P. 67 Harris v. Fall (C.C.A.), 177 F. 79,
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Of course, the Court is not blind to the reality that there


are times when danger to a patients life precludes a
surgeon from further searching missing sponges or foreign
objects left in the body. But this does not leave him free
from any obligation. Even if it has been shown that a
surgeon was required by the urgent necessities of the case
to leave a sponge in his patients abdomen, because of the
dangers attendant upon delay, still, it is his legal duty to so
inform his patient within a reasonable time thereafter by
advising her of what he had been compelled to do. This is in
order that she might seek relief from the effects of the
foreign object left in her body as 10her condition might
permit. The ruling in Smith v. Zeagler is explicit, thus:
The removal of all sponges used is part of a surgical operation,
and when a physician or surgeon fails to remove a sponge he has
placed in his patients body that should be removed as part of the
operation, he thereby leaves his operation uncompleted and
creates a new condition which imposes upon him the legal
duty of calling the new condition to his patients attention,
and endeavoring with the means he has at hand to
minimize and avoid untoward results likely to ensue
therefrom.

Here, Dr. Ampil did not inform Natividad about the


missing two pieces of gauze. Worse, he even misled her that
the pain she was experiencing was the ordinary consequence
of her operation. Had he been more candid, Natividad could

have taken the immediate and appropriate medical remedy


to remove the gauzes from her body. To our mind, what
was initially an act of negligence by Dr. Ampil has ripened
into a deliberate wrongful act of deceiving his patient.
This is a clear case of medical malpractice or more
appropriately, medical negligence. To successfully pursue
this kind of case, a patient must only prove that a health
care provider
_______________
27 L.R.A. (N.S.) 1174 Moore v. Ivey, (Tex. Civ. App.) 264 S.W. 283 21
R.C. L. 388.
10

157 So. 328 Fla. (1934)


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either failed to do something which a reasonably prudent


health care provider would have done, or that he did
something that a reasonably prudent provider would not
have done
and that failure or action caused injury to the
11
patient. Simply put, the elements are duty, breach, injury
and proximate causation. Dr, Ampil, as the lead surgeon,
had the duty to remove all foreign objects, such as gauzes,
from Natividads body before closure of the incision. When
he failed to do so, it was his duty to inform Natividad about
it. Dr. Ampil breached both duties. Such breach caused
injury to Natividad, necessitating her further examination
by American doctors and another surgery.
That Dr. Ampils
12
negligence is the proximate cause of Natividads injury
could be traced from his act of closing the incision despite
the information given by the attending nurses that two
pieces of gauze were still missing. That they were later on
extracted from Natividads vagina established the causal
link between Dr. Ampils negligence and the injury. And
what further aggravated such injury was
_______________
11

GarciaRueda v. Pascasio, G.R. No. 118141, September 5, 1997, 278

SCRA 769.
12

In the leading case of Vda. de Bataclan v. Medina, (102 Phil. 181

[1957]), this Court laid down the following definition of proximate cause in
this jurisdiction as follows:

[T]hat cause, which, in natural and continuous sequence unbroken by any efficient
intervening cause, produces the injury and without which the result would not
have occurred. And more comprehensively, the proximate cause is that acting first
and producing the injury, either immediately or by setting other events in motion,
all constituting a natural and continuous chain of events, each having a close
causal connection with the immediate predecessor, the final event in the chain
immediately effecting the injury as a natural and probable result of the cause
which first acted, under which circumstances that the person responsible for the
first event should, as an ordinarily prudent and intelligent person, have
reasonable ground to expect at the moment of his act or default that an injury to
some person might probably result therefrom.

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his deliberate concealment of the missing gauzes from the


knowledge of Natividad and her family.
IIG.R. No. 126467
Whether the Court of Appeals Erred in Absolving Dr.
Fuentes of any Liability
The Aganas assailed the dismissal by the trial court of the
case against Dr. Fuentes on the ground that it is contrary
to the doctrine of res ipsa loquitur. According to them, the
fact that the two pieces of gauze were left inside
Natividads body is a prima facie evidence of Dr. Fuentes
negligence.
We are not convinced.
Literally, res ipsa loquitur means the thing speaks for
itself. It is the rule that the fact of the occurrence of an
injury, taken with the surrounding circumstances, may
permit an inference or raise a presumption of negligence, or
make out a plaintiffs prima facie case, and present a
question of13 fact for defendant to meet with an
explanation. Stated differently, where the thing which
caused the injury, without the fault of the injured, is under
the exclusive control of the defendant and the injury is
such that it should not have occurred if he, having such
control used proper care, it affords reasonable evidence, in
the absence of explanation that the injury arose from the
defendants want of care, and the burden of proof is shifted
to him to14 establish that he has observed due care and
diligence.

From the foregoing statements of the rule, the requisites


for the applicability of the doctrine of res ipsa loquitur are:
(1) the occurrence of an injury (2) the thing which caused
the injury was under the control and management of the
defen
_______________
13

Ramos v. Court of Appeals, G.R. No. 124354, December 29, 1999, 321

SCRA 584.
14

Africa v. Caltex (Phils.) Inc., 123 Phil. 280 16 SCRA 448 (1966).
494

494

SUPREME COURT REPORTS ANNOTATED


Professional Services, Inc. vs. Agana

dant (3) the occurrence was such that in the ordinary


course of things, would not have happened if those who had
control or management used proper care and (4) the
absence of explanation by the defendant. Of the foregoing
requisites, the most instrumental is the control
and
15
management of the thing which caused the injury.
We find the element of control and management of the
thing which caused the injury to be wanting. Hence, the
doctrine of res ipsa loquitur will not lie.
It was duly established that Dr. Ampil was the lead
surgeon during the operation of Natividad. He requested
the assistance of Dr. Fuentes only to perform hysterectomy
when he (Dr. Ampil) found that the malignancy in her
sigmoid area had spread to her left ovary. Dr. Fuentes
performed the surgery and thereafter reported and showed
his work to Dr. Ampil. The latter examined it and finding
everything to be in order, allowed Dr. Fuentes to leave the
operating room. Dr. Ampil then resumed operating on
Natividad. He was about to finish the procedure when the
attending nurses informed him that two pieces of gauze
were missing. A diligent search was conducted, but the
misplaced gauzes were not found. Dr. Ampil then directed
that the incision be closed. During this entire period, Dr.
Fuentes was no longer in the operating room and had, in
fact, left the hospital.
Under the Captain of the Ship rule, the operating
surgeon is the person in complete charge of the surgery
room and all personnel connected
with the operation. Their
16
duty is to obey his orders. As stated before, Dr. Ampil was
the lead surgeon. In other words, he was the Captain of

the Ship. That he discharged such role is evident from his


following
_______________
15

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

control of the instrumentality which caused the damage, citing St.


Johns Hospital and School of Nursing v. Chapman, 434 P2d 160 (1967).
16

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

(1956).
495

VOL. 513, JANUARY 31, 2007

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Professional Services, Inc. vs. Agana

conduct: (1) calling Dr. Fuentes to perform a hysterectomy


(2) examining the work of Dr. Fuentes and finding it in
order (3) granting Dr. Fuentes permission to leave and (4)
ordering the closure of the incision. To our mind, it was this
act of ordering the closure of the incision notwithstanding
that two pieces of gauze remained unaccounted for, that
caused injury to Natividads body. Clearly, the control and
management of the thing which caused the injury was in
the hands of Dr. Ampil, not Dr. Fuentes.
In this jurisdiction, res ipsa loquitur is not a rule of
substantive law, hence, does not per se create or constitute
an independent or separate
ground of liability, being a
17
mere evidentiary rule. In other words, mere invocation
and application of the doctrine does not dispense with the
requirement of proof of negligence. Here, the negligence
was proven to have been committed by Dr. Ampil and not
by Dr. Fuentes.
IIIG.R. No. 126297
Whether PSI Is Liable for the Negligence of Dr. Ampil
The third issue necessitates a glimpse at the historical
development of hospitals and the resulting theories
concerning their liability for the negligence of physicians.
Until the midnineteenth century, hospitals were
generally charitable institutions, providing medical
services to the lowest classes
of society, without regard for
18
a patients ability to pay. Those who could afford medical
19
treatment were usually treated at home by their doctors.
However, the days of house calls and philanthropic health

care are over. The modern health care industry continues


to distance itself from its
_______________
17
18

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


Levin, Hospital Vicarious Liability for Negligence by Independent

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

Id.
496

496

SUPREME COURT REPORTS ANNOTATED


Professional Services, Inc. vs. Agana

charitable past and has experienced a significant


conversion from a notforprofit health care to forprofit
hospital businesses. Consequently, significant changes in
health law have accompanied the businessrelated changes
in the hospital industry. One important legal change is an
increase in hospital liability for medical malpractice. Many
courts now allow claims for hospital vicarious liability
under the theories of respondeat superior, apparent
20
authority, ostensible authority, or agency by estoppel.
In this jurisdiction, the statute governing liability for
negligent acts is Article 2176 of the Civil Code, which
reads:
Art. 2176. Whoever by act or omission causes damage to another,
there being fault or negligence, is obliged to pay for the damage
done. Such fault or negligence, if there is no preexisting
contractual relation between the parties, is called a quasidelict
and is governed by the provisions of this Chapter.

A derivative of this provision is Article 2180, the rule


governing vicarious liability under the doctrine of
respondeat superior, thus:
ART. 2180. The obligation imposed by Article 2176 is demandable
not only for ones own acts or omissions, but also for those of
persons for whom one is responsible.
x x x x x x
The owners and managers of an establishment or enterprise
are likewise responsible for damages caused by their employees in
the service of the branches in which the latter are employed or on
the occasion of their functions.
Employers shall be liable for the damages caused by their
employees and household helpers acting within the scope of their

assigned tasks even though the former are not engaged in any
business or industry.
x x x x x x
_______________
20

Id.
497

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497

Professional Services, Inc. vs. Agana


The responsibility treated of in this article shall cease when the
persons herein mentioned prove that they observed all the
diligence of a good father of a family to prevent damage.

A prominent civilist commented that professionals engaged


by an employer, such as physicians, dentists, and
pharmacists, are not employees under this article because
the manner in which they perform their work is not within
the control of the latter (employer). In other words,
professionals are considered personally liable for the fault
or negligence they commit in the discharge of their duties,
and their employer cannot be held liable for such fault or
negligence. In the context of the present case, a hospital
cannot be held liable for the fault or negligence of a
physician 21 or surgeon in the treatment or operation of
patients.
The foregoing view is grounded on the traditional notion
that the professional status and the very nature of the
physicians calling preclude him from being classed as an
agent or employee of 22a hospital, whenever he acts in a
professional capacity. It has been said that medical
practice strictly
involves highly developed and specialized
23
knowledge, such that physicians are generally free to
exercise their own skill
_______________
21

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

616.
22

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

Runyan v. Goodrum, 147 Ark. 281, 228 SW 397, 13 ALR 1403 (1921)
Rosane v. Senger, 112 Colo. 363, 149 P. 2d 372 (superseded by statute on
other grounds) Moon v. Mercy Hosp., 150 Col. 430, 373 P. 2d 944 (1962)
Austin v. Litvak, 682 P. 2d 41, 50 ALR 4th 225 (1984) Western Ins. Co. v.

Brochner, 682 P. 2d 1213 (1983) Rodriguez v. Denver, 702 P. 2d 1349


(1984).
23

Arkansas M.R. Co. v. Pearson, Id. Nieto v. State, 952 P. 2d 834

(1997). But see Beeck v. Tucson General Hosp., 18 Ariz. App. 165, 500 P.
2d 1153 (1972) Paintsville Hosp. Co., 683 SW 2d 255 (1985) Kelley v.
Rossi, 395 Mass. 659, 481 NE 2d 1340 (1985) which held that a physicians
professional status does not prevent him or her from being a servant or
agent of the hospital.
498

498

SUPREME COURT REPORTS ANNOTATED


Professional Services, Inc. vs. Agana

and judgment
in rendering medical services sans
24
interference. Hence, when a doctor practices medicine in a
hospital setting, the hospital and its employees are deemed
to subserve him in his ministrations25to the patient and his
actions are of his own responsibility.
The case
of Schloendorff v. Society of New York
26
Hospital was then considered an authority for this view.
The Schloendorff doctrine regards a physician, even if
employed by a hospital, as an independent contractor
because of the skill he exercises and the lack of control
exerted over his work. Under this doctrine, hospitals are
exempt from the application of the respondeat superior
principle for fault or negligence committed by physicians in
the discharge of their profession.
However, the efficacy of the foregoing doctrine has
weakened with the significant developments in medical
care. Courts came to realize that modern hospitals are
increasingly taking active role in supplying and regulating
medical care to patients. No longer were a hospitals
functions limited to furnishing room, food, facilities for
treatment and operation,27 and attendants for its patients.
Thus, in Bing v. Thunig, the New York Court of Appeals
deviated from the Schloendorff doctrine, noting that
modern hospitals actually do far more than provide
facilities for treatment. Rather, they regularly
_______________
24

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

25

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

26

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

Schloendorff opined that a hospital does not act through physicians but
merely procures them to act on their own initiative and responsibility. For

subsequent application of the doctrine, see for instance, Hendrickson v.


Hodkin, 250 App. Div 649, 294 NYS 982, revd on other grounds, 276 NY
252, 11 NE 2d 899 (1937) Necolayff v. Genesee Hosp., 270 App. Div. 648,
61 NYS 2d 832, affd 296 NY 936, 73 NE2d 117 (1946) Davie v. Lenox Hill
Hosp., Inc., 81 NYS 2d 583 (1948) Roth v. Beth El Hosp., Inc., 279 App.
Div 917, 110 NYS 2d 583 (1952) Rufino v. US, 126 F. Supp. 132 (1954)
Mrachek v. Sunshine Biscuit, Inc., 308 NY 116, 123 N.E. 2d 801 (1954).
27

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


499

VOL. 513, JANUARY 31, 2007

499

Professional Services, Inc. vs. Agana

employ, on a salaried basis, a large staff of physicians,


interns, nurses, administrative and manual workers. They
charge patients for medical care and treatment, even
collecting for such services through legal action, if
necessary. The court then concluded that there is no reason
to exempt hospitals from the universal rule of respondeat
superior.
In our shores, the nature of the relationship between the
hospital and the physicians is rendered inconsequential in
view of our
categorical pronouncement in Ramos v. Court of
28
Appeals that for purposes of apportioning responsibility in
medical
negligence
cases,
an
employeremployee
relationship in effect exists between hospitals and their
attending and visiting physicians. This Court held:
We now discuss the responsibility of the hospital in this
particular incident. The unique practice (among private hospitals)
of filling up specialist staff with attending and visiting
consultants, who are allegedly not hospital employees, presents
problems in apportioning responsibility for negligence in medical
malpractice cases. However, the difficulty is more apparent than
real.
In the first place, hospitals exercise significant control
in the hiring and firing of consultants and in the conduct
of their work within the hospital premises. Doctors who
apply for consultant slots, visiting or attending, are
required to submit proof of completion of residency, their
educational
qualifications,
generally,
evidence
of
accreditation by the appropriate board (diplomate),
evidence of fellowship in most cases, and references. These
requirements are carefully scrutinized by members of the
hospital administration or by a review committee set up
by the hospital who either accept or reject the application.
x x x.

After a physician is accepted, either as a visiting or


attending consultant, he is normally required to attend
clinicopathological conferences, conduct bedside rounds
for clerks, interns and residents, moderate grand rounds
and patient audits and perform other tasks and
responsibilities, for the
_______________
28

Supra at footnote 13.

500

500

SUPREME COURT REPORTS ANNOTATED


Professional Services, Inc. vs. Agana

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


and/or for the privilege of admitting patients into the
hospital. In addition to these, the physicians performance as a
specialist is generally evaluated by a peer review committee on
the basis of mortality and morbidity statistics, and feedback from
patients, nurses, interns and residents. A consultant remiss in
his duties, or a consultant who regularly falls short of the
minimum standards acceptable to the hospital or its peer
review committee, is normally politely terminated.
In other words, private hospitals, hire, fire and exercise
real control over their attending and visiting consultant
staff. While consultants are not, technically employees, x
x x, the control exercised, the hiring, and the right to
terminate consultants all fulfill the important hallmarks of
an employeremployee relationship, with the exception of
the payment of wages. In assessing whether such a
relationship in fact exists, the control test is determining.
Accordingly, on the basis of the foregoing, we rule that for the
purpose of allocating responsibility in medical negligence
cases, an employeremployee relationship in effect exists
between hospitals and their attending and visiting
physicians.

But the Ramos pronouncement is not our only basis in


sustaining PSIs liability. Its liability is also anchored upon
the agency principle of apparent authority or agency by
estoppel and the doctrine of corporate negligence which
have gained acceptance in the determination of a hospitals
liability for negligent acts of health professionals. The
present case serves as a perfect platform to test the
applicability of these doctrines, thus, enriching our
jurisprudence.

Apparent authority, or what is sometimes referred to as


the holding out theory,
or doctrine of ostensible agency or
29
agency by estoppel, has its origin from the law of agency.
It
_______________
29

Blacks Law Dictionary (6th Ed. 1990) 1100. The terms ostensible

agency, agency by estoppel, apparent authority, and holding out


tend to be used interchangeably by the courts to refer to this theory of
liability. See for instance, Baker v. Werner, 654 P2d 263 (1982) and
Adamski v. Tacoma Gen. Hosp., 20 Wash App. 98,
501

VOL. 513, JANUARY 31, 2007

501

Professional Services, Inc. vs. Agana

imposes liability, not as the result of the reality of a


contractual relationship, but rather because of the actions
of a principal or an employer in somehow misleading the
public 30into believing that the relationship or the authority
exists. The concept is essentially one of estoppel and has
been explained in this manner:
The principal is bound by the acts of his agent with the apparent
authority which he knowingly permits the agent to assume, or
which he holds the agent out to the public as possessing. The
question in every case is whether the principal has by his
voluntary act placed the agent in such a situation that a person of
ordinary prudence, conversant with business usages and the
nature of the particular business, is justified in presuming that
such agent
has authority to perform the particular act in
31
question.

The applicability of apparent authority in the field of


hospital liability was upheld long time ago in Irving v.
Doctor Hos
_______________
579 P2d 970 (1978). Agency by estoppel is defined as one created by
operation of law and established by proof of such acts of the principal as
reasonably lead third persons to the conclusion of its existence. Arises
where principal by negligence in failing to supervise agents affairs, allows
agent to exercise powers not granted to him, thus justifying others in
believing the agent possesses requisite authority. Blacks, supra, p. 62.
An ostensible agency is an implied or presumptive agency which exists

where one, either intentionally or from want of ordinary care, induces


another to believe that a third person is his agent, though he never in fact,
employed him. It is, strictly speaking, no agency at all, but is in reality
based entirely upon estoppel. Apparent authority refers to the power to
affect the legal relations of another person by transactions with third
persons, professedly as agent for the other, arising from and in accordance
with the others manifestations to such third persons. Supra, p. 96.
30

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

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

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

608, 186 A 437 (Sup. Ct. 1936).


502

502

SUPREME COURT REPORTS ANNOTATED


Professional Services, Inc. vs. Agana
32

pital of Lake Worth, Inc. There, it was explicitly stated


that there does not appear to be any rational basis for
excluding the concept of apparent authority from the field of
hospital liability. Thus, in cases where it can be shown
that a hospital, by its actions, has held out a particular
physician as its agent and/or employee and that a patient
has accepted treatment from that physician in the
reasonable belief that it is being rendered in behalf of the
hospital, then the hospital will be liable for the physicians
negligence.
Our jurisdiction recognizes the concept of an agency by
implication or estoppel. Article 1869 of the Civil Code
reads:
ART. 1869. Agency may be express, or implied from the acts of
the principal, from his silence or lack of action, or his failure to
repudiate the agency, knowing that another person is acting on
his behalf without authority.

In this case, PSI publicly displays in the lobby of the


Medical City Hospital the names and specializations of the
physicians associated or accredited by it, including those of
Dr. Ampil and Dr. Fuentes. We concur with the Court of
Appeals conclusion that it is now estopped from passing
all the blame to the physicians whose names it proudly
paraded in the public directory leading the public to believe
that it vouched for their skill and competence. Indeed,
PSIs act is tantamount to holding out to the public that
Medical City Hospital, through its accredited physicians,
offers quality health care services. By accrediting Dr.
Ampil and Dr. Fuentes and publicly advertising their

qualifications, the hospital created the impression that


they were its agents, authorized to perform medical or
surgical services for its patients. As expected, these
patients, Natividad being one of them, accepted the
services on the reasonable belief that such were being
rendered by the hospital or its employees, agents, or
servants. The trial court correctly pointed out:
_______________
32

Supra.
503

VOL. 513, JANUARY 31, 2007

503

Professional Services, Inc. vs. Agana


x x x regardless of the education and status in life of the
patient, he ought not be burdened with the defense of
absence of employeremployee relationship between the
hospital and the independent physician whose name and
competence are certainly certified to the general public by
the hospitals act of listing him and his specialty in its
lobby directory, as in the case herein. The high costs of
todays medical and health care should at least exact on
the hospital greater, if not broader, legal responsibility for
the conduct of treatment and surgery within its facility by
its accredited physician or surgeon,
regardless of whether
33
he is independent or employed.

The wisdom of the foregoing ratiocination is easy to


discern. Corporate entities, like PSI, are capable of acting
only through other individuals, such as physicians. If these
accredited physicians do their job well, the hospital
succeeds in its mission of offering quality medical services
and thus profits financially. Logically, where negligence
mars the quality of its services, the hospital should not be
allowed to escape liability for the acts of its ostensible
agents.
We now proceed to the doctrine of corporate negligence
or corporate responsibility.
One allegation in the complaint in Civil Case No. Q
43332 for negligence and malpractice is that PSI as owner,
operator and manager of Medical City Hospital, did not
perform the necessary supervision nor exercise diligent
efforts in the supervision of Drs. Ampil and Fuentes and its
nursing staff, resident doctors, and medical interns who
assisted Drs. Ampil and Fuentes in the performance of their
34

duties as surgeons. Premised on the doctrine of corporate

34

duties as surgeons. Premised on the doctrine of corporate


negligence, the trial court held that PSI is directly liable for
such breach of duty.
We agree with the trial court.
_______________
33

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

34

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


504

504

SUPREME COURT REPORTS ANNOTATED


Professional Services, Inc. vs. Agana

Recent years have seen the doctrine of corporate negligence


as the judicial answer to the problem of allocating
hospitals liability for the negligent acts of health
practitioners, absent facts to support the application of
respondeat superior or apparent authority. Its formulation
proceeds from the judiciarys acknowledgment that in these
modern times, the duty of providing quality medical service
is no longer the sole prerogative and responsibility of the
physician. The modern hospitals have changed structure.
Hospitals now tend to organize a highly professional
medical staff whose competence and performance need to
be monitored by the hospitals commensurate with their
35
inherent responsibility to provide quality medical care.
The doctrine has 36its genesis in Darling v. Charleston
Community Hospital. There, the Supreme Court of Illinois
held that the jury could have found a hospital negligent,
inter alia, in failing to have a sufficient number of trained
nurses attending the patient failing to require a
consultation with or examination by members of the
hospital staff and failing to review the treatment rendered
to the patient. On the basis of Darling, other jurisdictions
held that a hospitals corporate negligence extends to
permitting a physician
known to be incompetent to practice
37
at the hospital. With the passage of time, more duties
were expected from hospitals, among them: (1) the use of
reasonable care in the maintenance of safe and adequate
facilities and equipment (2) the selection and retention of
competent physicians (3) the overseeing or supervision of all
persons who practice medicine within its walls and (4) the
formulation, adoption and enforcement of adequate rules
_______________

35

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

36

Supra at footnote 1.

37

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

Law Div.1975) Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d 335


(1972) Hospital Authority v. Joiner, 229 Ga. 140,189 S.E. 2d 412 (1972).
505

VOL. 513, JANUARY 31, 2007

505

Professional Services, Inc. vs. Agana


38

and policies that ensure quality care for its patients.


39
Thus, in Tucson Medical Center, Inc. v. Misevich, it was
held that a hospital, following the doctrine of corporate
responsibility, has the duty to see that it meets the
standards of responsibilities for the care of patients. Such
duty includes the proper supervision40of the members of its
medical staff. And in Bost v. Riley, the court concluded
that a patient who enters a hospital does so with the
reasonable expectation that it will attempt to cure him. The
hospital accordingly has the duty to make a reasonable
effort to monitor and oversee the treatment prescribed and
administered by the physicians practicing in its premises.
In the present case, it was duly established that PSI
operates the Medical City Hospital for the purpose and
under the concept of providing comprehensive medical
services to the public. Accordingly, it has the duty to
exercise reasonable care to protect from harm all patients
admitted into its facility for medical treatment.
Unfortunately, PSI failed to perform such duty. The
findings of the trial court are convincing, thus:

x x x PSIs liability is traceable to its failure to conduct an


investigation of the matter reported in the nota bene of
the count nurse. Such failure established PSIs part in the
dark conspiracy of silence and concealment about the
gauzes. Ethical considerations, if not also legal, dictated the
holding of an immediate inquiry into the events, if not for the
benefit of the patient to whom the duty is primarily owed, then in
the interest of arriving at the truth. The Court cannot accept that
the medical and the healing professions, through their members
like defendant surgeons, and their institutions like PSIs hospital
facility, can callously turn their backs on and disregard even a
mere probability of mistake or negligence by refusing or failing to
investigate a report of such seriousness as the one in Natividads
case.

_______________
38

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

39

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

40

262 S.E. 2d 391, cert denied 300 NC 194, 269 S.E. 2d 621 (1980).
506

506

SUPREME COURT REPORTS ANNOTATED


Professional Services, Inc. vs. Agana

It is worthy to note that Dr. Ampil and Dr. Fuentes


operated on Natividad with the assistance of the Medical
City Hospitals staff, composed of resident doctors, nurses,
and interns. As such, it is reasonable to conclude that PSI,
as the operator of the hospital, has actual or constructive
knowledge of the procedures carried out, particularly the
report of the attending nurses that the
two pieces of gauze
41
were missing. In Fridena v. Evans, it was held that a
corporation is bound by the knowledge acquired by or
notice given to its agents or officers within the scope of
their authority and in reference to a matter to which their
authority extends. This means that the knowledge of any of
the staff of Medical City Hospital constitutes knowledge of
PSI. Now, the failure of PSI, despite the attending nurses
report, to investigate and inform Natividad regarding the
missing gauzes amounts to callous negligence. Not only did
PSI breach its duties to oversee or supervise all persons who
practice medicine within its walls, it also failed to take an
active step in fixing the negligence committed. This renders
PSI, not only vicariously liable for the negligence of Dr.
Ampil under Article 2180 of the Civil Code, but also
directly liable for its own negligence under Article 2176.
In Fridena, the Supreme Court of Arizona held:
x x x In recent years, however, the duty of care owed to the
patient by the hospital has expanded. The emerging trend is to
hold the hospital responsible where the hospital has failed
to monitor and review medical services being provided
within its walls. See Kahn Hospital Malpractice Prevention, 27
De Paul Rev. 23 (1977).
Among the cases indicative of the emerging trend is Purcell v.
Zimbelman, 18 Ariz. App. 75,500 P. 2d 335 (1972). In Purcell, the
hospital argued that it could not be held liable for the malpractice
of a medical practitioner because he was an independent
contractor within the hospital. The Court of Appeals pointed
out that the hospital had created a professional staff
whose competence

_______________
41

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

507

VOL. 513, JANUARY 31, 2007

507

Professional Services, Inc. vs. Agana

and performance was to be monitored and reviewed by the


governing body of the hospital, and the court held that a
hospital would be negligent where it had knowledge or
reason to believe that a doctor using the facilities was
employing a method of treatment or care which fell below
the recognized standard of care.
Subsequent to the Purcell decision, the Arizona Court of
Appeals held that a hospital has certain inherent
responsibilities regarding the quality of medical care
furnished to patients within its walls and it must meet the
standards of responsibility commensurate with this
undertaking. Beeck v. Tucson General Hospital, 18 Ariz. App.
165, 500 P. 2d 1153 (1972). This court has confirmed the rulings
of the Court of Appeals that a hospital has the duty of supervising
the competence of the doctors on its staff. x x x.
x x x x x x
In the amended complaint, the plaintiffs did plead that the
operation was performed at the hospital with its knowledge, aid,
and assistance, and that the negligence of the defendants was the
proximate cause of the patients injuries. We find that such
general allegations of negligence, along with the evidence
produced at the trial of this case, are sufficient to support
the hospitals liability based on the theory of negligent
supervision.

Anent the corollary issue of whether PSI is solidarily liable


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

508

508

SUPREME COURT REPORTS ANNOTATED


Professional Services, Inc. vs. Agana

his profession. At the same time, he must apply reasonable


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