G.R. No. 204095 - Cruz vs. Agas, Jr.

Case Summary (G.R. No. 204095)

Factual Background

Petitioner alleged that in late May 2003 he was admitted to SLMC for gastroscopy and colonoscopy. After sedation and the endoscopic examination, he awakened with symptoms (dizziness, diaphoresis, breathing difficulty, extreme abdominal pain) and subsequently collapsed. He was referred to surgery, underwent an emergency exploratory laparotomy on May 30, 2003, and learned that a 6–8 inch portion of the left colon had been excised because of a partial tear of the colonic wall causing internal bleeding. He alleged persistent postoperative symptoms (difficulty digesting food, melena, loss of appetite, pain) and claimed that Dr. Agas admitted performing the colonoscopy but denied any error.

Respondent’s Defense

Dr. Agas denied negligence or reckless imprudence and insisted that petitioner had confabulated failures. He averred that he had conferred with petitioner and reviewed his medical history before the procedure, that vitals were stable and the procedures were initially successful, and that he observed proper standards and precautions. Supporting evidence included a counter-affidavit and certifications/sworn statements from SLMC personnel (Assistant Medical Director for Professional Services, Director of the Institute of Digestive Diseases, the anesthesiologist, and a nurse) and a Hospital Ethics Committee certification attesting to adequate care and that the colonoscopy was properly performed. Dr. Agas explained that the intraperitoneal bleeding and serosal tear were caused by preexisting abnormal adhesions and tortuosity of petitioner’s sigmoid colon—conditions not detectable prior to laparotomy and not visible on colonoscopy (which inspects the mucosal surface, not the serosa).

Proceedings at Prosecutorial and DOJ Levels

The OCP dismissed the complaint for serious physical injuries through reckless imprudence and medical malpractice (Feb. 16, 2004). The DOJ affirmed that dismissal (Mar. 2, 2007) and denied petitioner’s motion for reconsideration (Sept. 23, 2009). The DOJ thus found lack of probable cause to file criminal information against Dr. Agas.

Court of Appeals Decision

The CA affirmed the DOJ. It applied the well-settled rule that courts will not interfere with the public prosecutor’s wide discretion in determining probable cause in a preliminary investigation absent grave abuse of discretion. The CA found no such grave abuse here. It held that petitioner failed to specify in his complaint the particular acts or omissions constituting negligence or reckless imprudence, and that Dr. Agas’s counter-affidavit, supported by medical and hospital affidavits and the Hospital Ethics Committee certification, adequately explained that the complication resulted from an abnormal colonic condition (marked adhesions and tortuosity) not discoverable by preoperative studies or by colonoscopy. The CA therefore concluded petitioner did not establish probable cause.

Standard of Judicial Review of Probable Cause (Separation of Powers)

Under the doctrine of separation of powers embodied in the 1987 Constitution, the courts generally defer to the executive’s prosecutorial discretion in preliminary investigations. Judicial intervention is warranted only when the executive determination is tainted by grave abuse of discretion—an act so patent and gross as to amount to evasion of a positive duty or an arbitrary exercise of power. The CA and the Supreme Court applied this standard in assessing whether the DOJ’s dismissal exceeded prosecutorial discretion.

Elements and Proof Required in Medical Negligence Claims

Medical negligence requires proof of duty, breach (failure to conform to the required standard of care), injury, and proximate causation linking the breach to the injury. The patient/plaintiff bears the burden of demonstrating that the health care provider either failed to do what a reasonably prudent practitioner would have done or did something that a reasonably prudent practitioner would not have done, and that such failure or action caused the injury. The existence of mere adverse results from a medical procedure does not automatically establish negligence.

Applicability of Res Ipsa Loquitur

Res ipsa loquitur permits an inference of negligence from the mere occurrence of an injury when (1) the injury occurred, (2) the instrumentality causing it was under the defendant’s control, (3) the injury ordinarily would not have occurred absent negligence, and (4) the defendant does not explain the occurrence. The pivotal requisite is control of the instrumentality. In this case the Court found res ipsa loquitur inapplicable because the alleged negligence was not immediately apparent to a layman and because respondent provided an explanation—supported by medical affidavits—that the serosal tear and bleeding resulted from preexisting adhesions and colon configuration beyond the colonoscope’s reach and beyond the endoscopist’s ability to detect preoperatively.

Application of Law to the Case Facts

Applying the foregoing standards, the courts concl

Case Syllabus (G.R. No. 204095)

Case Citation and Procedural Posture

Supreme Court decision reported at 759 Phil. 504, Second Division, G.R. No. 204095, dated June 15, 2015.
Petition for review on certiorari under Rule 45 of the Rules of Court assails:
- May 22, 2012 Decision and October 18, 2012 Resolution of the Court of Appeals in CA-G.R. SP No. 111910.
- Those CA rulings affirmed the Department of Justice (DOJ) Resolutions of March 2, 2007 and September 23, 2009.
- The DOJ resolutions let stand the February 16, 2004 Resolution of the Office of the City Prosecutor (OCP) of Quezon City dismissing the complaint filed by petitioner Dr. Jaime T. Cruz.
Supreme Court opinion penned by Justice Mendoza; concurrence by Carpio (Chairperson), Brion, Del Castillo, and Jardeleza, JJ.
Acting member designation noted: Justice Jardeleza designated Acting Member in lieu of Associate Justice Marvic M.V.F. Leonen per Special Order No. 2056 dated June 10, 2015.

Parties and Nature of the Action

Petitioner: Dr. Jaime T. Cruz, who filed a Complaint-Affidavit for Serious Physical Injuries through Reckless Imprudence and Medical Malpractice.
Respondent: Dr. Felicisimo V. Agas, Jr., accused of medical negligence arising from a colonoscopy and gastroscopy performed at St. Luke’s Medical Center (SLMC).
Relief sought: review of prosecutorial and DOJ determinations dismissing the criminal complaint against respondent and reversal of CA affirmation.

Facts and Clinical Course Alleged by Petitioner

Timeline of events:
- May 28, 2003: Petitioner admitted to St. Luke’s Medical Center for medical check-up.
- May 29, 2003: Sent to Gastro-Enterology Department for scheduled gastroscopy and colonoscopy; colonoscopy performed after sedation.
- May 30, 2003: Petitioner awakened in ICU after emergency exploratory laparotomy for internal bleeding.
- June 7, 2003: Petitioner discharged from SLMC.
Allegations by Dr. Cruz:
- Prior to procedure, the specialist assigned was allegedly “nowhere to be found,” and the colonoscopy results were given to the attending female anesthesiologist for the assigned specialist’s consideration.
- After sedation and endoscopic examination, petitioner experienced dizziness, cold clammy perspiration, breathing difficulty, inability to sit or stand, extreme abdominal pain, and collapse while attempting to urinate.
- Cardiologist Dr. Agnes Del Rosario observed critical condition and referred petitioner to surgical department which suspected intra-abdominal hemorrhage and advised emergency surgery.
- During exploratory laparotomy, a portion of the left colon measuring 6–8 inches was cut because of a partial tear of the colonic wall causing internal bleeding.
- Postoperative course included pain at incision site, fever, intravenous lines, subclavian arterial access on the left chest, and a nasogastric tube.
- Continued postoperative problems: difficulty digesting, early satiety requiring frequent feeds, fresh blood in stools with bowel movements, loss of appetite, gastric acidity, excessive sleeping, and persistent weakness, tiredness, and pain.
- Petitioner asserted that respondent admitted performing the colonoscopy but denied that anything went wrong.

Respondent’s Defense and Explanations

Main defenses asserted by Dr. Agas:
- Denied that petitioner proved the basic elements of reckless imprudence or negligence.
- Contended petitioner mischaracterized whether respondent knew he would perform the procedure; respondent conferred with petitioner and reviewed medical history prior to starting.
- Maintained that gastroscopy and colonoscopy were completely successful, petitioner did not manifest significant adverse reactions during the procedures, and vital signs were normal throughout.
- Asserted that the intraperitoneal bleeding that developed after the procedure was immediately recognized, evaluated, managed, and corrected.
- Emphasized he provided an adequate and reasonable standard of care, followed all precautionary measures, and did not deviate from standard medical norms, practices, or procedures.
Explanatory theory offered by respondent regarding cause of injury:
- Complication arose from an abnormal condition and configuration of petitioner’s digestive system, specifically marked adhesions and tortuosity of the sigmoid colon, not from negligent act during colonoscopy.
- Tear in the serosa (outermost layer of colonic wall) likely occurred because interloop adhesions detached from the serosa during the procedure.
- Such marked adhesions cannot be detected prior to endoscopy by clinical findings, laboratory tests, or diagnostic imaging (x-ray, ultrasound, CT scan) and are detectable only by surgical opening of the abdomen.
- The colonoscope visualizes the inner lining only; damage to the outer wall (serosa) without colon perforation cannot be caused by the colonoscope contacting the serosa.

Evidence Supporting Respondent’s Position

Submitted certifications, sworn statements, and affidavits:
- Assistant Medical Director for Professional Services and Director of the Institute of Digestive Diseases attested to appropriate management of the bleeding and adequacy of care.
- Sworn affidavit of anesthesiologist Dr. Jennifel S. Bustos
...continue reading