G.R. No. 167366 - Cereno vs. Court of Appeals

Case Summary (G.R. No. 167366)

Factual Background

On the evening of 16 September 1995, Raymond Olavere, a stabbing victim, was brought to the emergency room of the Bicol Regional Medical Center (BRMC) and was initially attended by Nurse Arlene Balares and emergency resident physician Dr. Ruel Levy Realuyo. After initial treatment, Dr. Realuyo recommended emergency exploratory laparotomy and requested 500 cc of type O blood, which Raymond’s father and uncle procured from the Philippine National Red Cross and delivered to the hospital at about 11:15 P.M. At about 10:30 P.M. the hospital surgeons Drs. Zafe and Cereno were operating on a gunshot victim, assisted anesthetically by Dr. Rosalina Tatad, head of the BRMC Anesthesiology Department. A subsequent obstetric emergency occupied Dr. Tatad, and the surgeons examined Raymond and found normal blood pressure and, according to Dr. Cereno’s interpretation of x-rays, minimal intrathoracic fluid of about 200–300 cc. The operation on Raymond commenced at about 12:15 A.M. on 17 September 1995. Upon opening the thoracic cavity the surgeons found approximately 3,200 cc of blood, evacuated the blood, and discovered a puncture at the inferior pole of the left lung. Blood transfusion was begun at 1:40 A.M. During the operation Raymond suffered cardiac arrest at 1:45 A.M., the operation ended at 1:50 A.M., and he was pronounced dead at 2:30 A.M. The death certificate listed the immediate cause of death as hypovolemic shock.

Trial Court Proceedings

On 25 October 1995 the parents of Raymond filed a complaint for damages against Nurse Balares, Dr. Realuyo, and attending surgeons Dr. Cereno and Dr. Zafe in the RTC, Branch 22, Naga City. The plaintiffs testified and presented lay witnesses. Petitioners and other hospital personnel testified in defense. On 15 October 1999 the RTC dismissed the case against Dr. Realuyo and Nurse Balares for lack of merit and found Drs. Zafe and Cereno negligent. The RTC ordered the surgeons jointly and severally to pay P50,000 for death, P150,000 as moral damages, P100,000 as exemplary damages, P30,000 for attorney’s fees, and costs. The trial court grounded liability on the surgeons’ delay in performing the operation after the earlier surgery concluded, on their failure to call or otherwise secure a standby anesthesiologist pursuant to a supposed BRMC protocol, and on an alleged delay in transfusing blood.

Court of Appeals Decision

The Court of Appeals affirmed the RTC decision in toto in its 21 February 2005 decision in CA-G.R. CV No. 65800. The CA found Drs. Cereno and Zafe guilty of gross negligence in the performance of their duties and sustained the award of damages to the private respondents.

Issues Presented on Review

In their petition under Rule 45, Rules of Court, petitioners advanced three principal grounds: that the CA erred in ruling that petitioners were grossly negligent in the performance of their duties; that the CA erred in not treating BRMC as an indispensable party and subsidiarily liable should petitioners be found liable; and that the CA erred in not finding the awards of moral and exemplary damages and attorney’s fees exorbitant or excessive. Petitioners sought reversal and setting aside of the CA decision.

Supreme Court Ruling

The Supreme Court granted the petition, reversed and set aside the Court of Appeals decision dated 21 February 2005, and ordered no costs. The Court observed the limited scope of review under Rule 45, Rules of Court, which confines this Court principally to questions of law and generally affords finality to factual findings of the CA, but recognized exceptions where factual conclusions are grounded on speculation or where the judgment is based on a misapprehension of facts. The Court found such exceptions applicable in this case.

Legal Basis and Reasoning

The Court recited the governing law on medical negligence, requiring proof that a health care provider breached the standard of care and that such breach proximately caused the injury. The Court emphasized the need for competent expert testimony from practitioners in the same field to establish deviation from the standard of care and causation. Addressing the trial court’s finding of negligence for failure to procure a standby anesthesiologist, the Court found no competent evidence that petitioners knew of the BRMC protocol referenced in Dr. Tatad’s testimony. The Court held that absent proof that petitioners were aware of the protocol, they could not be faulted for failing to comply with it. The Court further reasoned ex gratia argumenti that even if the protocol existed and petitioners had known of it, the protocol vested authority to call the standby anesthesiologist in the head of the Anesthesiology Department; Dr. Tatad, who had discretion, was already engaged in another emergency. The Court noted unrebutted findings by the petitioners that Raymond’s vital signs and x-ray interpretation did not indicate imminent massive blood loss at the time, thus rendering the decision to await Dr. Tatad’s availability reasonable. The Court criticized the trial court’s reliance on Dr. Tatad’s testimony alone, observing that she was not an expert in surgical decision making and that the plaintiffs produced no surgical expert to contradict petitioners’ course of action. On the alleged delay in transfusion, the Court held that petitioners were not shown to be responsible for any cross-matching delay and accepted Dr. Cereno’s unchallenged

Case Syllabus (G.R. No. 167366)

Parties and Procedural Posture

Dr. Pedro Dennis Cereno and Dr. Santos Zafe were the petitioners before the Supreme Court seeking review under Rule 45, Rules of Court.
Spouses Diogenes S. Olavere and Fe R. Serrano were the private respondents and parents and heirs of the deceased patient Raymond Olavere.
The petition assailed the 21 February 2005 decision of the Court of Appeals in CA-G.R. CV No. 65800 which had affirmed the trial court judgment finding petitioners liable for damages.
The Supreme Court granted the petition and reversed and set aside the Court of Appeals decision.

Key Factual Allegations

Raymond Olavere arrived at Bicol Regional Medical Center with stabbing injuries at about 9:15 P.M. on 16 September 1995 and was initially attended by Nurse Arlene Balares and Dr. Ruel Levy Realuyo.
Drs. Zafe and Cereno were operating on another emergency patient, Charles Maluluy-on, while Dr. Rosalina Tatad, the only senior anesthesiologist on duty and head of the Anesthesiology Department, assisted other cases.
Drs. Zafe and Cereno examined Raymond after the Maluluy-on operation and found his blood pressure normal and an x-ray showing minimal thoracic fluid estimated at 200–300 cc.
Raymond’s parents procured 500 cc type O blood and delivered it at about 11:15 P.M., which was handed to Dr. Realuyo for cross-matching.
Petitioners commenced surgery on Raymond at about 12:15 A.M. of 17 September 1995 and discovered approximately 3,200 cc of blood in the thoracic cavity and a puncture at the inferior pole of the left lung.
Blood was transfused at 1:40 A.M., Raymond suffered cardiac arrest at 1:45 A.M., and he was pronounced dead at 2:30 A.M., with the death certificate citing hypovolemic shock as the immediate cause.

Procedural History

A complaint for damages was filed before the Regional Trial Court, Branch 22, Naga City on 25 October 1995 against Nurse Balares, Dr. Realuyo, Dr. Cereno, and Dr. Zafe.
The RTC rendered judgment on 15 October 1999 dismissing claims against Dr. Realuyo and Nurse Balares and finding Drs. Zafe and Cereno jointly and severally liable awarding P50,000 for death, P150,000 moral damages, P100,000 exemplary damages, P30,000 attorneys’ fees, and costs.
The Court of Appeals affirmed the RTC decision in its 21 February 2005 decision in CA-G.R. CV No. 65800.
The Supreme Court granted the petition under Rule 45, Rules of Court and reversed and set aside the CA decision.

Issues

Whether Drs. Cereno and Zafe were guilty of gross negligence in the performance of their duties.
Whether the Bicol Regional Medical Center (BRMC) was an indispensable party and subsidiarily liable if the petitioners were found liable.
Whether the awards of moral and exemplary damages and attorneys’ fees were excessive.

Contentions

Petitioners contended that they were not negligent because the assignment and administration of anesthesia were within the prerogative of the Anesthesiology Department and because they reasonably relied on the availability and judgment of the anesthesiologist on duty.
Petitioners further contended that any delay in cross-matching or transfusion of blood was not their fault and that transfusion was deferred during surgery to control bleeding.
Private respondents contended that petitioners delayed surgery and transfusion, that a