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

Case Summary (G.R. No. 167366)

Key Dates and Procedural Posture

Incident: Night of 16–17 September 1995. Complaint filed: 25 October 1995 before RTC, Branch 22, Naga City. RTC decision: 15 October 1999 (found petitioners negligent and ordered damages). Court of Appeals decision: 21 February 2005 (affirmed RTC). Supreme Court disposition: grant of Petition for Review on Certiorari and reversal and setting aside of CA decision (petition granted).

Facts Material to Liability

Raymond, a stabbing victim, was brought to BRMC and treated in ER; surgeons Zafe and Cereno were operating on another emergency (gunshot victim) when Raymond was ready for surgery. The senior anesthesiologist, Dr. Tatad, became engaged in a concurrent obstetric emergency. Petitioners examined Raymond preoperatively and found stable blood pressure and minimal thoracic fluid per their interpretation of x-ray (200–300 cc). Petitioners deferred immediate operation until Dr. Tatad completed her other case. A 500 cc unit of type O blood was procured by Raymond’s relatives and turned over to Dr. Realuyo at ~11:15 P.M.; cross-matching and availability issues followed. Petitioners began surgery at about 12:15 A.M.; on opening the thorax they found ~3,200 cc of blood and a puncture at the inferior pole of the left lung. Blood transfusion was given at 1:40 A.M.; Raymond suffered cardiac arrest during surgery and was pronounced dead. Death certificate listed immediate cause as hypovolemic shock.

Claims and Trial Court Ruling

The parents sued for damages against attending nurses and physicians. The RTC dismissed claims against Nurse Balares and Dr. Realuyo but found Drs. Zafe and Cereno negligent for (a) delay in operating on Raymond after completing another operation, (b) failing to request a standby anesthesiologist, and (c) delay in transfusing blood. The RTC awarded compensatory, moral, and exemplary damages, attorney’s fees, and costs.

Court of Appeals Ruling

The CA affirmed the RTC in toto, finding gross negligence by petitioners and upholding the awards of damages.

Issues Raised on Petition for Review

Petitioners asserted (1) the CA erred in finding gross negligence; (2) the CA erred in not impleading BRMC as an indispensable party and in not holding it subsidiarily liable; and (3) the CA erred in upholding awards of moral and exemplary damages and attorney’s fees as excessive.

Standard of Review under Rule 45 and Applicable Exceptions

The Supreme Court reiterated that under Rule 45 only questions of law may be raised; factual findings of the CA are generally final. The Court listed the recognized exceptions permitting factual reexamination (including conclusions grounded on speculation, and judgments based on misapprehension of facts). The Court applied exceptions (1) speculation/surmise and (4) misapprehension of facts in this case.

Legal Standard for Medical Negligence and Proof

The Court restated that a medical negligence action requires proof that the health-care provider breached the standard of care and that such breach proximately caused the injury. Expert testimony from practitioners in the same field is ordinarily indispensable to prove both breach and causation because laymen cannot reliably assess technical medical conduct.

Analysis — Delay in Performing Surgery and Requesting Standby Anesthesiologist

The Supreme Court held that the RTC/CA erred in imputing negligence to petitioners for not immediately operating after concluding the other surgery. Two principal reasons supported reversal: (1) there was no competent evidence that petitioners knew of a BRMC protocol making the standby anesthesiologist directly available to surgeons; the only testimony about such a protocol came from Dr. Tatad and did not establish that petitioners were aware of it or routinely practiced under it; and (2) even assuming such a protocol existed and was known, the decision to wait was reasonable in context—Dr. Tatad was engaged in another critical operation, petitioners’ preoperative assessment showed normal blood pressure and minimal intrathoracic fluid (their findings went unrebutted), and there was no expert testimony presented by plaintiffs to show that a prudent surgeon would have acted differently. The Court emphasized that Dr. Tatad’s expertise was in anesthesia, not in surgical diagnosis or the timing of surgery, limiting the probative value of her testimony on whether immediate surgery was required.

Analysis — Delay in Blood Transfusion

The Court found the trial court’s conclusion that petitioners negligently delayed transfusion to be mistaken. The alleged delay in cross-matching and availability of blood was not shown to be attributable to petitioners and was beyond their control. Petitioners’ unchallenged testimony explained the clinical decision not to transfuse earlier: prior to surgery there was no indication of gross bleeding requiring transfusion; during the operation immediate transfusion was deferred to control active bleeding first because transfusing before securing hemostasis would have resulted in loss of transfused blood. Those explanations went unrebutted and no expert evidence contradicted them.

Causation and Burden of Proof

The Court held that respondents failed to prove, within reasonable medical probabili

Case Syllabus (G.R. No. 167366)

Facts

On the evening of 16 September 1995 at about 9:15 P.M., Raymond S. Olavere (Raymond), a stabbing victim, was brought to the emergency room of Bicol Regional Medical Center (BRMC).
Raymond was initially attended by Nurse Arlene Balares and Dr. Ruel Levy Realuyo, the emergency room resident physician.
Raymond’s parents, spouses Diogenes (Deogenes in some parts of the record) S. Olavere and Fe R. Serrano, arrived with Andrew Olavere (Raymond’s uncle).
Dr. Realuyo recommended an emergency exploratory laparotomy and requested 500 cc of type A O+ A blood for the operation; Deogenes and Andrew went to the Philippine National Red Cross to procure the blood.
At 10:30 P.M., Raymond was wheeled into the operating room while Drs. Santos Zafe and Pedro Dennis Cereno were engaged in operating on gunshot victim Charles Maluluy-on.
Dr. Rosalina Tatad, the only senior anesthesiologist on duty that night and head of the BRMC Anesthesiology Department, assisted the Maluluy-on operation and then began work on an emergency obstetric operation for Lilia Aguila, a woman giving birth to triplets.
The Maluluy-on operation concluded at 10:59 P.M., but Dr. Tatad was already committed to the Aguila operation; in light of this and the absence of another available anesthesiologist, Drs. Zafe and Cereno deferred Raymond’s operation and examined him.
Petitioners found Raymond’s blood pressure normal and “nothing in him was significant”; Dr. Cereno interpreted an x-ray as showing minimal fluid in the thoracic cavity (about 200–300 cc).
At 11:15 P.M., Deogenes and Andrew returned with the requested 500 cc type A blood and handed it to Dr. Realuyo.
Petitioners commenced the operation on Raymond at around 12:15 A.M. on 17 September 1995; upon opening the thoracic cavity they found 3,200 cc of blood and evacuated it, discovering 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., the operation ended at 1:50 A.M., and Raymond was pronounced dead at 2:30 A.M.
Raymond’s death certificate listed immediate cause of death as “hypovolemic shock,” i.e., cessation of bodily functions due to loss of blood.

Procedural History

On 25 October 1995, Raymond’s parents filed a complaint for damages in RTC, Branch 22, Naga City, against Nurse Balares, Dr. Realuyo, and surgeons Dr. Cereno and Dr. Zafe, alleging negligence.
At trial, the parents and witnesses Andrew Olavere and Loira Oira testified for plaintiffs; petitioners and others testified for the defense; on rebuttal plaintiffs presented Dr. Tatad among others.
On 15 October 1999, the RTC rendered judgment: dismissed the case against Dr. Ruel Levy Realuyo and Arlene Balares for lack of merit; ordered Drs. Zafe and Cereno to pay heirs of Raymond jointly and severally P50,000.00 for death, P150,000.00 moral damages, P100,000.00 exemplary damages, P30,000.00 attorney’s fees, and costs of suit.
The Court of Appeals, in a decision dated 21 February 2005 (CA-G.R. CV No. 65800), affirmed the RTC decision in toto, finding petitioners guilty of gross negligence and awarding damages to respondents.
Petitioners filed a Petition for Review on Certiorari under Rule 45 of the Rules of Court before the Supreme Court, assailing the CA decision on three main grounds: (1) error in ruling petitioners grossly negligent; (2) error in not considering BRMC as an indispensable party and subsidiarily liable; and (3) error in not finding moral and exemplary damages and attorney’s fees excessive.

Trial Court’s Findings and Judgment (Dispositive)

Trial court concluded petitioners were negligent for not immediately performing surgery on Raymond after finishing the Maluluy-on operation, holding that prompt surgery would have prevented excessive blood loss and saved Raymond.
Trial court found non-availability of Dr. Tatad was not an excuse, citing her testimony about a BRMC protocol allowing a standby anesthesiologist to be called and that petitioners could have requested Dr. Tatad to call the standby anesthesiologist.
Trial court faulted petitioners for delay in transfusion of blood, noting that the 500 cc blood was brought at 11:15 P.M. but remained for cross-matching and was not transfused until 1:40 A.M.
Dispositive portion ordered dismissal against Realuyo and Balares; ordered Drs. Zafe and Cereno to pay P50,000 death, P150,000 moral, P100,000 exemplary, P30,000 attorney’s fees, plus costs.

Court of Appeals’ Ruling

The CA affirmed the RTC decision in toto on 21 February 2005, finding petitioners guilty of gross negligence in performance of their duties and affirming the award of damages to the private respondents.

Issues Presented to the Supreme Court

Whether the CA erred in ruling petitioners were grossly negligent in the performance of their duties.
Whether the CA erred in not considering BRMC as an indispensable party and subsidiarily liable should petitioners be found liable.
Whether the CA erred in not finding the awards of moral and exemplary damages and attorney’s fees exhorbitant or excessive.

Standard of Review and Rule 45 Limitations

The petition was under Rule 45; only questions of law may be raised on review.
The Supreme Court is not a trier of facts and generally will not re-examine or re-evaluate evidence on record; factual findings of the CA affirming trial court are generally final and conclusive.
Listed exceptions where factual findings may be disturbed: (1) conclusions grounded on speculations, surmises or conjectures; (2) inference manifestly mistaken, absurd or impossible; (3) grave abuse of discretion; (4) judgment based on misapprehension of facts; (5) conflicting findings of fact; (6) no citation of specific evidence for findings; (7) findings of absence of fact contradicted by presence of evidence; (8) CA findings contrary to those of trial court; (9) CA manifestly ov