Case Summary (G.R. No. 159132)
Pertinent Dates and Applicable Law
Critical dates: initial admission July 28, 1994; D&C performed July 30, 1994; second admission and laparotomy September 16, 1994; complaint filed November 7, 1994; Board of Medicine decision March 4, 1999; PRC decision November 22, 2000; Court of Appeals decision July 4, 2003; Supreme Court decision (reviewed) December 18, 2008. Applicable law and rules relied upon in the decision: 1987 Philippine Constitution (due process), Republic Act No. 2382 (Medical Act of 1959, Section 26), Rules and Regulations Governing the Regulation and Practice of Professionals (Art. IV, Sec. 35, later amended), PRC Res. No. 06‑342(A) (2006 Rules of Procedure), Rules of Court (Rule 43 and Rule 65), and civil law standards for quasi‑delict (Articles 2176, 2179 of the Civil Code).
Procedural Posture
Respondents filed an administrative complaint for gross negligence and malpractice before the Professional Regulations Commission (PRC). The Board of Medicine initially exonerated petitioner. Respondents appealed to the PRC, which reversed the Board and revoked petitioner’s license. Petitioner sought judicial relief: first to the Court of Appeals (which dismissed the petition on procedural grounds), then to the Supreme Court by Rule 45 petition for review on certiorari.
Core Facts of the Medical Events
On July 28, 1994 Editha was admitted for vaginal bleeding; sonogram showed weak fetal cardiac pulsation and later no fetal movement. Petitioner, after telephone coordination and hospital admission, conducted internal examinations on July 29 and July 30, 1994, found an open cervix and advised D&C because of persistent, profuse bleeding and expulsion by the patient of "meaty mass" and clots. D&C was performed July 30, 1994; patient discharged July 31 with instructions to return for follow‑up on August 4 (or August 5 as advised). Editha did not return. On September 16, 1994 she presented with severe abdominal pain and vomiting; laparotomy revealed massive intra‑abdominal hemorrhage and a ruptured uterus due to an ectopic interstitial (cornual) placenta increta, necessitating hysterectomy.
Allegations Against Petitioner
Respondents alleged that petitioner committed gross negligence and professional incompetence by: (1) failing to check, visit, or administer medication on the first day of confinement; (2) recommending D&C without an internal examination; (3) immediately suggesting D&C instead of monitoring the pregnancy; and (4) failing to remove the fetus during D&C, which respondents claimed caused the later rupture and need for hysterectomy.
Petitioner’s Answer and Defenses
Petitioner denied negligence and asserted she: arranged admission and telephone orders before patient arrival; visited during rounds; performed internal examinations on July 29 and 30 and found an open cervix; repeatedly advised D&C only because of profuse bleeding and the patient’s symptoms; observed no abortus in the operating room and relied on the patient’s description of expelled material; discharged the patient only with instruction to return for follow‑up; and maintained that the underlying pathology was an abnormal ectopic placental implantation (placenta increta/ectopic interstitial) that would have ruptured irrespective of the D&C.
Board of Medicine Findings
The Board found the case to be an ectopic interstitial pregnancy (a rare form protected by uterine musculature) and concluded the D&C could not have reached or removed an ectopic pregnancy located outside the uterine cavity; curettage is intrauterine and cannot remove an ectopic gestation. The Board therefore exonerated petitioner, explaining that obstetricians reasonably assume intrauterine pregnancy unless sonologist specifies otherwise, and that the D&C was necessary to control profuse bleeding.
PRC Decision Revoking License
On appeal, the PRC reversed the Board of Medicine and revoked petitioner’s license to practice medicine. The PRC decision became the subject of judicial proceedings.
Court of Appeals Ruling and Reasoning
The Court of Appeals held that the petition for review (Rule 43) filed by petitioner in the CA was an improper remedy because Rule 43 enumerates quasi‑judicial agencies whose decisions may be reviewed and the PRC was not expressly listed; the CA treated the petition as improperly filed. The CA further held that if treated as certiorari under Rule 65, the petition was premature or improper because Section 26 of R.A. No. 2382 provided a plain, speedy and adequate remedy — appeal to the Office of the President — and thus certiorari was not the correct recourse.
Supreme Court Issues Presented
Petitioner raised procedural and substantive errors: (1) whether PRC decisions fall under Rule 43 appellate jurisdiction to the Court of Appeals; (2) whether the PRC improperly entertained an appeal by complainants; (3) whether the CA committed grave abuse by dismissing the petition without addressing merits; (4) whether PRC violated petitioner’s due process by accepting and deciding the memorandum on appeal without proof of service; (5) whether PRC’s revocation lacked expert support and disregarded Board findings; and (6) whether PRC made factual conclusions contrary to the record.
Jurisdictional and Procedural Analysis by the Court
The Supreme Court concluded: (a) double jeopardy does not apply to administrative proceedings, so Section 26’s appeal provisions do not implicate constitutional double jeopardy rights; (b) the prior limitation that only respondents may appeal Board decisions was amended—Art. IV, Sec. 35 (as amended) and later PRC procedural rules expressly allow either complainant or respondent, or “a party aggrieved,” to appeal to the PRC; (c) Rule 43’s enumeration of quasi‑judicial agencies is illustrative, not exhaustive; B.P. Blg. 129 and subsequent jurisprudence confer appellate jurisdiction on the Court of Appeals over PRC decisions; therefore the CA was incorrect to dismiss on the sole ground that PRC was not enumerated in Rule 43.
Substantive Standard for Medical Malpractice and Expert Testimony
The Court recited the governing standards: medical malpractice is negligence requiring proof of duty, breach, injury and proximate causation; the physician‑patient relationship establishes the duty of reasonable care; determinations of standard of care and causation in medical malpractice cases ordinarily require expert testimony because causation and standards are scientific questions beyond lay competence.
Expert Testimony and Court’s Evaluation
Respondents presented no expert witness to support their theory that the D&C caused the rupture; petitioner presented expert testimony from Dr. Augusto M. Manalo (qualified obstetrician‑gynecologist). Dr. Manalo diagnosed a ruptured ectopic interstitial (cornual) pregnancy and testified that (1) D&C instruments could not reach an interstitial ectopic site and thus could not have caused the rupture; and (2) if D&C were causative the rupture would have occurred much earlier, not one and a half months later. He also testified regarding customary practice (inspection of scanty curettings, telephone ord
...continue readingCase Syllabus (G.R. No. 159132)
Parties and Nature of the Case
- Petitioner: Dr. Fe Cayao-Lasam, a licensed physician who performed a dilatation and curettage (D&C) procedure on Editha Ramolete.
- Respondents: Spouses Claro and Editha Ramolete, complainants below who brought charges for gross negligence and malpractice.
- Nature of the proceeding before the Supreme Court: Petition for Review on Certiorari under Rule 45 of the Rules of Court seeking annulment of the Court of Appeals decision in CA-G.R. SP No. 62206 dated July 4, 2003.
- Relief sought by petitioner: Annulment of the Court of Appeals decision and vindication of petitioner’s professional standing and actions.
Antecedent Facts — Clinical Chronology and Immediate Events
- July 28, 1994: Editha Ramolete, three months pregnant, was brought to Lorma Medical Center (LMC) in San Fernando, La Union because of vaginal bleeding.
- On arrival/that day: Petitioner, after being informed by telephone, advised admission; a pelvic sonogram revealed the fetus’ weak cardiac pulsation.
- July 29, 1994: Repeat pelvic sonogram showed weak fetal cardiac pulsation and absence of appreciable fetal movement.
- Persistent and profuse vaginal bleeding led petitioner to advise a Dilatation and Curettage (D&C) procedure.
- July 30, 1994: Petitioner performed the D&C procedure.
- July 31, 1994: Editha was discharged from the hospital the following day after the D&C.
- September 16, 1994: Editha returned to LMC suffering from vomiting and severe abdominal pains; attending physicians included Drs. Beatriz de la Cruz, Victor B. Mayo and Juan V. Komiya.
- After laparotomy: Massive intra-abdominal hemorrhage and a ruptured uterus were found; Editha underwent hysterectomy and consequently became unable to bear children.
- Alleged diagnosis by physicians at laparotomy: a dead fetus and findings consistent with an ectopic/interstitial pregnancy (as later described in findings).
Administrative Complaint and Allegations of Negligence
- November 7, 1994: Respondents filed a Complaint for Gross Negligence and Malpractice against petitioner before the Professional Regulations Commission (PRC).
- Principal allegations against petitioner included:
- Failure to check up on, visit, or administer medication to Editha during her first day of confinement at LMC.
- Recommending a D&C without conducting any internal examination prior to the procedure.
- Immediately suggesting D&C instead of closely monitoring the pregnancy.
- Failure to remove the fetus from Editha’s womb during the procedure.
- Respondents alleged that petitioner’s negligence and incompetence caused Editha’s subsequent hysterectomy.
Petitioner’s Answer and Defense
- Petitioner denied negligence and explained her actions as follows:
- Upon knowing of Editha’s intention to seek admission, petitioner called the hospital to prepare and ordered medicines by telephone which nurses administered.
- Petitioner visited Editha on the morning of July 28 during rounds.
- On July 29, she performed an internal examination and found an open cervix; she discussed D&C as a possible course if bleeding worsened.
- On July 30, another internal exam showed the cervix still open; Editha complained of persistent vaginal bleeding and the passage of “some meaty mass” during urination/bowel movement, and petitioner advised D&C with respondents’ consent.
- In the operating room petitioner was “very vocal” about not being able to see an abortus; she interpreted Editha’s report of expelled tissue as meaning the abortus may have already been expelled.
- Editha insisted on discharge; petitioner agreed but advised return for check-up on August 5, 1994, which Editha failed to do.
- Petitioner asserted that Editha’s failure to follow-up and insistence on discharge against medical advice contributed to the later life-threatening condition.
- Petitioner contended Editha’s condition was placenta increta/ectopic interstitial pregnancy — an extremely rare, abnormal placental implantation — and that uterus rupture would have occurred regardless of D&C.
Administrative and Judicial Proceedings — Lower Decisions
- March 4, 1999: Board of Medicine of the PRC rendered a Decision exonerating petitioner.
- Board’s key findings: laparotomy findings indicated Ectopic Pregnancy Interstitial; ultrasound did not specify fetal location; obstetricians reasonably assume intrauterine pregnancy unless sonologist specifies otherwise; D&C was necessary to control profuse bleeding given an open cervix; curettage cannot remove a fetus located outside the uterus.
- November 22, 2000: PRC reversed the Board of Medicine’s findings and revoked petitioner’s license to practice medicine.
- Petitioner sought judicial relief by filing a petition for review under Rule 43 (and styled as one under Rule 65) with the Court of Appeals.
- July 4, 2003: Court of Appeals held the petition for review under Rule 43 was improper because the PRC was not listed among quasi-judicial agencies enumerated in Rule 43, and further held that a petition for certiorari (Rule 65) was improper and premature because petitioner had an adequate remedy of appeal to the Office of the President under Section 26 of R.A. No. 2382 (The Medical Act of 1959).
Issues Presented to the Supreme Court
- Procedural questions:
- Whether the PRC is excluded from the quasi-judicial agencies covered by Rule 43 and consequently whether a Rule 43 petition to the Court of Appeals was improper.
- Whether, if PRC were excluded, petitioner could still avail of petition for certiorari (Rule 65) where the PRC decision was allegedly in excess of or without jurisdiction or a patent nullity.
- Whether respondents (complainants before the Board) are allowed by law to appeal the Board’s decision to the PRC.
- Whether the Court of Appeals committed grave abuse of discretion by denying review on the merits due to alleged improper forum.
- Whether PRC violated petitioner’s due process by accepting and considering respondents’ memorandum on appeal without proof of service to petitioner.
- Whether PRC committed grave abuse of discretion by revoking petitioner’s license without expert testimony supporting the cause of Editha’s injury and by disregarding the Board’s findings and Dr. Augusto M. Manalo’s testimony.
- Whether PRC’s factual conclusions were unsupported or contrary to the record.
- Substantive question:
- Whether petitioner was guilty of medical malpractice/professional negligence that proximately caused Editha’s hysterectomy.
Legal Framework and Authorities Considered
- Procedural statutes and rules mentioned:
- Rule 43 of the Rules of Court (Appeals from the Court of Tax Appeals and quasi-judicial agencies to the Court of Appeals); Section 1 quoted and discussed.
- Rule 45 and Rule 65 invoked in procedural posture.
- R.A. No. 2382 (The Medical Act of 1959), Section 26 on appeals from Board decisions.
- Article IV, Section 35 of the Rules and Regulations Governing the Regulation and Practice of Professionals (appeal to the Commission) and its subsequent amendment (Reg. Res. 174, Series 1990).
- PRC Resolution No. 06-342(A) (New Rules of Procedure in Administrative Inves