Case Summary (G.R. No. 1331)
Key Dates and Procedural Milestones
Clinical events: Carmen admitted around 11:30 p.m., February 2, 1992; cesarean section performed February 3, 1992; postoperative problems and diagnosis of UTI early February 4, 1992; second operation on February 12, 1992; death on February 13, 1992. Trial court decision: Regional Trial Court (Olongapo City, Branch 75) dated January 28, 2003. Court of Appeals decision: December 15, 2009 (reversing trial court). Supreme Court resolution: petition for review denied (decision reference in the prompt).
Facts as Found by the Parties
Carmen delivered a baby via cesarean section on February 3, 1992. She experienced postoperative abdominal pain, urinary difficulty, and was diagnosed with urinary tract infection and treated. By February 10 her abdomen was enlarging; Dr. Norma initially described it as flatulence. A second operation was recommended and performed on February 12, 1992; petitioner and Carmen signed consent for this procedure. Carmen’s condition worsened, she vomited dark red blood on February 13 and died that night. The hospital death certificate listed cardio‑respiratory arrest secondary to cerebrovascular accident, hypertension and chronic nephritis induced by pregnancy; the autopsy by Dr. Patilano attributed death to shock due to severe peritonitis with multiple intestinal adhesions status post cesarean section and exploratory laparotomy.
Trial Court Proceedings and Evidence
Pedrito filed a complaint for damages alleging respondents failed to exercise required professional diligence and were negligent in performing surgery. Respondents denied negligence, asserted appropriate care, and counterclaimed for unpaid hospital bills and sought damages. At trial, petitioner relied principally on the testimony and autopsy report of Dr. Patilano to establish causal connection between surgical care and Carmen’s death. Respondents presented testimony from Dr. Nestor explaining the medical necessity of the cesarean section and the subsequent exploratory laparotomy for intestinal obstruction due to adhesions, and relied on documentary evidence of consent and respondents’ medical conduct. Dr. Torres testified that Dr. Patilano did not examine certain vital organs during autopsy.
Trial Court Decision
The RTC credited Dr. Patilano’s testimony and autopsy findings, concluded respondents were negligent, and awarded actual damages, indemnity for death, moral and exemplary damages, attorney’s fees, and costs. The award was premised on the trial court’s acceptance of the autopsy‑based conclusions that Carmen’s death was attributable to peritonitis and related surgical factors.
Court of Appeals Ruling
The CA reversed the RTC, finding that petitioner failed to establish that the respondents breached the standard degree of care required of medical practitioners or that any breach proximately caused Carmen’s death. The CA also allowed respondents’ counterclaim and ordered petitioner to pay the unpaid hospital bills, professional fees, and expenses in the stipulated amount of P48,515.58.
Issues Presented on Certiorari
The central issues were whether the respondents committed medical negligence in treating Carmen and whether petitioner proved, with competent expert evidence, that any alleged negligence was the proximate cause of death. Secondary issue was the validity of respondents’ counterclaim for unpaid hospital charges.
Governing Legal Standards for Medical Negligence
The Court applied settled principles: a medical malpractice claim requires proof that (1) a physician had a duty to the patient, (2) there was a breach of that duty measured by the degree of care, skill and diligence ordinarily exercised by physicians of the same general neighborhood and specialty, (3) injury occurred, and (4) proximate causation linking the breach to the injury. Proof of breach and causation ordinarily requires competent expert testimony establishing negligence and causation within a reasonable medical probability; verdicts cannot rest on speculation or conjecture.
Assessment of Expert Evidence and Autopsy Report
The Supreme Court agreed with the CA that the autopsy report and Dr. Patilano’s testimony were insufficient to establish the standard of care and causation. The Court observed that Dr. Patilano’s qualifications and specialization relevant to the obstetric and surgical issues were not established, that his conclusions were based solely on postmortem findings without adequate consideration of Carmen’s clinical course, medical history, or the emergency nature of the initial cesarean section, and that his autopsy did not appear to follow basic procedures (failure to examine several vital organs) as noted by Dr. Torres. Because Dr. Patilano’s findings were limited by methodological shortcomings and absence of comprehensive clinical context, they could not, by themselves, support a finding of breach or causal linkage to the respondents’ conduct.
Respondents’ Evidence and Proffered Justifications
Respondents presented testimony that the first cesarean section was necessary for full‑term pregnancy with pre‑eclampsia, fetal distress and active labor; that Carmen’s persistent hypertension justified extended monitoring; that the second operation addressed suspected intestinal obstruction due to adhesions; and that both Carmen and petitioner gave written consent for the second surgery. Dr. Nestor’s surgical training and long experience (since 1970) was relied upon to establish that the
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Procedural History
- Petition for review on certiorari filed by petitioner Pedrito Dela Torre (Pedrito) assailing the Decision dated December 15, 2009 and Resolution dated July 27, 2010 of the Court of Appeals (CA) in CA-G.R. CV No. 78534. [Rollo citations as in source]
- The case originated from a complaint for damages filed by Pedrito against respondents Dr. Arturo Imbuido and Dr. Norma Imbuido (Dr. Norma), owners/operators of Divine Spirit General Hospital, and Dr. Nestor Pasamba (Dr. Nestor).
- Regional Trial Court (RTC) of Olongapo City, Branch 75, rendered judgment on January 28, 2003 in favor of Pedrito (Judge Edgar Chua); the RTC awarded actual, indemnity, moral and exemplary damages, attorney’s fees and costs of suit.
- The respondents appealed to the Court of Appeals, which on December 15, 2009 reversed and set aside the RTC decision and granted the respondents’ counterclaim for unpaid hospital bills, professional fees and other expenses in the amount of P48,515.58.
- Supreme Court resolution (Reyes, J.) denied the petition; the Decision of the CA dated December 15, 2009 and Resolution dated July 27, 2010 in CA-G.R. CV No. 78534 were affirmed. The decision was rendered September 29, 2014 and the notice of judgment indicates receipt on October 29, 2014.
- Members of the Supreme Court who concurred in the affirmance: Velasco, Jr. (Chairperson), Peralta, Villarama, Jr., and Jardeleza, JJ.
Factual Background: Clinical Timeline and Events
- Carmen Castillo Dela Torre (Carmen) was married to petitioner Pedrito and was due to give birth on February 2, 1992.
- Carmen was brought to Divine Spirit General Hospital at around 11:30 p.m. on February 2, 1992 by Pedrito.
- Dr. Norma discussed with Pedrito the possibility of a caesarean section when Carmen still had not delivered at the expected time.
- At around 3:00 p.m. on February 3, 1992, Carmen was brought to the hospital’s operating room for a caesarian section to be performed by Dr. Nestor. By 5:30 p.m. of the same day Pedrito was informed of his wife’s delivery of a baby boy.
- Early morning of February 4, 1992: Carmen experienced abdominal pain and difficulty urinating; diagnosed with urinary tract infection (UTI) and prescribed medications by Dr. Norma.
- February 10, 1992: Pedrito noticed Carmen’s stomach was getting bigger; Dr. Norma dismissed the condition as flatulence (kabag).
- When Carmen’s abdominal enlargement persisted, Dr. Norma advised Pedrito of the possibility of a second operation but gave no details on its purpose or the surgeon who would perform it.
- At around 3:00 p.m. on February 12, 1992, Carmen underwent a second operation. Later that evening Dr. Norma informed Pedrito that “everything was going on fine with [his] wife.”
- February 13, 1992: Carmen’s condition worsened; she vomited dark red blood and died at 9:30 p.m.
- Death certificate (per information provided by the hospital) listed immediate cause as “cardio-respiratory arrest secondary to cerebro vascular accident, hypertension and chronic nephritis induced by pregnancy.”
- Autopsy report prepared by Dr. Richard Patilano, Medico-Legal Officer-Designate of Olongapo City, provided the cause of death as “shock due to peritonitis, severe, with multiple intestinal adhesions; Status post C[a]esarian Section and Exploratory Laparotomy.”
Claims, Defenses, and Counterclaim
- Petitioner’s claim: respondents “failed to exercise the degree of diligence required of them as members of the medical profession” and were “negligent for practicing surgery on [Carmen] in the most unskilled, ignorant and cruel manner,” thereby causing her death.
- Respondents’ defense: they “observed the required standard of medical care in attending to the needs of Carmen.” Carmen was admitted for pregnancy in labor and pre-eclampsia, closely monitored, and a caesarian section became necessary due to lack of progress for spontaneous delivery. No unusual events occurred during the caesarian section. The second surgery was performed for suspected intestinal obstruction and adhesions, a condition confirmed and resolved intraoperatively. The second procedure was “fully explained to Carmen and Pedrito prior to its conduct.” Despite due care, Carmen died on February 13, 1992.
- Respondents’ counterclaim: claimed P48,515.58 as unpaid hospital charges, professional fees and medicines; additionally sought P3,000,000.00 for moral damages, P1,500,000.00 for exemplary damages, and attorney’s fees.
Evidence and Testimony at Trial
- For petitioner: testimony of Dr. Richard Patilano, medicolegal officer who conducted the autopsy upon a telephone request made by the City Health Officer (Dr. Generoso Espinosa). Dr. Patilano observed intestines more reddish than normal (pinkish), presence of adhesions with dilated areas and constricted areas; concluded there might have been foreign organic matter in the intestines; concluded cause of death was peritonitis with multiple adhesions status post caesarian section. He explained peritonitis may be caused by infections, entrance of foreign bodies, ruptured peptic ulcer or splenic injury, and in surgical operations may be due to non-aseptic instruments, materials or assistants not in uniform. He stated peritonitis could have been prevented through proper medical procedures and medicines. He also stated that if the cause were cerebro-vascular accident there would be ruptured blood vessels and blood clots in the head, which were absent in Carmen’s case.
- For respondents: testimony of Dr.