Case Summary (G.R. No. 189218)
Key Dates and Procedural Posture
Operative events: Emergency C-section performed 26 December 1997; deterioration began in early hours of 27 December 1997; Regina discharged from Cardinal Santos Hospital in vegetative state on 19 January 1998 and died 11 May 2005. Trial court (RTC) decision dated 29 December 2006; Court of Appeals decision dated 24 October 2008; Supreme Court decision rendered 22 March 2017. The petition to the Supreme Court was a Rule 45 petition raising primarily legal questions from the CA ruling.
Applicable Law and Legal Sources
Primary substantive law applied: Civil Code provisions on quasi-delict and employer liability — Article 2176 (general duty to prevent damage through fault or negligence) and Article 2180 (employer liability for employees; burden to prove diligence of a “good father of a family” in selection and supervision). Procedural and evidentiary rules referenced: Rules of Court, Rule 45 (appellate review); precedents cited include Ramos v. CA and Nacar v. Gallery Frames. Statutory background on nursing: R.A. 7164 (and later R.A. 9173) referenced regarding nursing duties and standards. The decision was rendered under the framework of the 1987 Constitution as the applicable constitutional era for decisions after 1990.
Facts: Medical Event Summary
Regina Capanzana, a 40‑year‑old nurse pregnant with her third child, underwent an emergency Caesarean section at petitioner hospital on 26 December 1997 after going into active labour. She initially stabilized and was transferred to a regular ward. Approximately 13 hours after operation (around 2:30 a.m. on 27 December 1997) she developed headache, chilliness, restlessness, shortness of breath, and cyanosis; she requested oxygen. An x‑ray showed pulmonary edema; she was transferred to ICU and placed on a mechanical ventilator. Impression at the hospital was amniotic fluid embolism. Later transfer to Cardinal Santos Hospital yielded a diagnosis of rheumatic heart disease with mitral stenosis and mild pulmonary hypertension; a cardio‑pulmonary arrest followed, producing hypoxic encephalopathy and resultant loss of speech, sight, hearing, and motor function, and later a vegetative state.
Claims, Defenses and Relief Sought
Plaintiffs alleged negligence by the attending physicians (failure to detect rheumatic heart disease, failure to obtain cardiology clearance, and failure to provide appropriate intra‑ and post‑operative management), negligence by nurses for delayed response and failure to promptly deliver oxygen, and hospital negligence for not making oxygen available and for inadequate supervision of staff. Plaintiffs sought actual, compensatory, moral and exemplary damages, attorney’s fees, and other relief. Defendants denied liability: doctors asserted that no signs of heart disease were present on examination, that the operation was emergent and cardiac clearance was not feasible, and that amniotic fluid embolism was an unforeseeable event; the hospital and certain staff denied instruction to place a standby oxygen tank and denied negligent delay.
Trial Evidence and Key Testimony
Plaintiffs presented medical experts (cardiologists, neurologist/neurosurgeon) and lay testimony including Balad, who was watching Regina overnight and testified that nurses delayed responding to repeated buzz calls (10–20 minutes) and that Regina repeatedly asked for oxygen and showed signs of cyanosis. Defense presented attending physicians, nursing administration witnesses, and documentary nursing records. Discrepancies in nurse schedules, erased or inconsistent entries in Nurses’ Notes, and adverse personnel records concerning tardiness/absences among nurses were part of the record. The nurses’ deposition of Evelyn David was sought by petitioner late in the proceedings but the RTC denied leave.
RTC Findings and Rationale
The RTC found no negligence by Drs. Ramos and Santos, concluding that standard medical practices were observed and that the proximate cause of Regina’s vegetative state was an amniotic fluid embolism, an event not reasonably preventable. The RTC, however, found negligence by the nurses for delayed response in providing oxygen and in referring the patient to physicians; expert testimony supported that delay contributed to hypoxic encephalopathy. Because jurisdiction was obtained only over Florita Ballano among the on‑duty staff, the RTC held Ballano liable and dismissed the hospital and the physicians from liability, finding the hospital had exercised due diligence in selection and supervision based on its hiring and supervisory procedures.
Court of Appeals Ruling and Modifications
The CA affirmed the RTC’s factual finding that the proximate cause of Regina’s brain damage was hypoxic encephalopathy secondary to pulmonary/cardiac arrest on pulmonary edema, but it modified liability findings. The CA accepted that Drs. Ramos and Santos did not breach standard practices and affirmed their exoneration. The CA, unlike the RTC, declined to hold Ballano personally liable (noting uncertainty whether she was among the attending nurses and that she was a midwife rather than a nurse). The CA instead held the hospital directly liable under corporate responsibility (Article 2180) because it found the hospital had not proved adequate supervision and because the hospital admitted non‑availability of sufficient oxygen tanks on the ward — constituting gross negligence. The CA awarded the same damage sums as the RTC but made the hospital liable for payment.
Supreme Court: Standard for Medical Negligence and Deference to Findings of Fact
The Supreme Court reiterated that under Rule 45 it reviews questions of law and ordinarily defers to factual findings of the lower courts, absent exceptional circumstances. It confirmed the legal standard for medical negligence requires proof by preponderance of duty, breach, injury, and proximate causation; medical expertise is employed to establish standards and causation. The Court accepted the lower courts’ factual findings that nurses delayed responding to Regina’s repeated calls, that oxygen delivery was delayed (testimony placed the delay at 10–20 minutes), and that hypoxic brain injury can occur within five minutes of oxygen deprivation. The Court therefore affirmed the breach by nurses and the causal link between that breach (delayed oxygenation and delayed referral) and Regina’s hypoxic encephalopathy.
Supreme Court: Employer Liability — Selection vs Supervision
Applying Article 2180 in relation to Article 2176, the Court noted that employer liability is direct once employee negligence is established, and the employer must prove it exercised the diligence of a good father of a family in both selection and supervision to be exonerated. The Court found the hospital had presented credible evidence of a rigorous selection/hiring process, but the preponderance of evidence supported the CA’s conclusion that the hospital failed to prove adequate supervision. The Court emphasized that proof of mere policies or hierarchical structures is insufficient; there must be evidence of actual implementation, monitoring, and disciplining. Documentary and testimonial inconsistencies (contradictory duty rosters, altered entries, omitted Nurse’s Notes pages, personnel records showing habitual tardiness and absenteeism without sanction) supported the conclusion that the hospital did not discharge its supervisory burden. Accordingly, the Supreme Court affirmed direct liability of the hospital for its nurses’ negligence under Articles 2176 and 2180.
Supreme Court: Medical Causation Disposition (Amniotic Fluid Embolism vs Rheumatic Heart Disease)
The Court accepted the lower courts’ determinatio
...continue readingCase Syllabus (G.R. No. 189218)
Antecedent Facts
- Regina Capanzana, a 40‑year‑old nurse and clinical instructor pregnant with her third child, went into active labor on 26 December 1997 and was brought to Our Lady of Lourdes Hospital for an emergency cesarean section; she had been scheduled for a third C‑section on 2 January 1998.
- Prior to the emergency operation, Regina underwent a pre‑operative physical examination by Dr. Miriam (Mirriam) Ramos and Dr. Milagros Joyce (Jocelyn) Santos, who had been the attending physicians in her prior childbirths; she reportedly responded negatively to questions regarding tuberculosis, rheumatic fever, and cardiac diseases and was found fit for anesthesia.
- Regina delivered a baby boy on 26 December 1997; after stabilization she was transferred from the recovery room to a regular hospital room.
- At about 2:30 a.m. on 27 December 1997 (roughly 13 hours after the operation) Regina, watched by her niece Katherine L. Balad, complained of headache, chilliness, restlessness, and shortness of breath; she asked for oxygen and later became cyanotic.
- An x‑ray revealed pulmonary edema; she was transferred to the Intensive Care Unit and placed on mechanical ventilation; the working impression at the hospital was signs of amniotic fluid embolism.
- On 2 January 1998 Regina was transferred to Cardinal Santos Hospital where physicians found rheumatic heart disease, mitral stenosis with mild pulmonary hypertension contributing to pulmonary edema; she suffered cardiopulmonary arrest leading to hypoxic encephalopathy (brain damage), losing speech, eyesight, hearing and limb function and was discharged in a vegetative state on 19 January 1998.
- Regina died on 11 May 2005; she was later substituted in the action by her heirs represented by Romeo Capanzana.
Parties, Claims and Reliefs Sought
- Plaintiffs: Spouses Romeo and Regina Capanzana (later represented by Romeo after Regina’s death).
- Defendants: Our Lady of Lourdes Hospital (petitioner); Dr. Miriam Ramos (obstetrician/gynecologist); Dr. Milagros Joyce Santos (anesthesiologist); unnamed nurses on duty (Jane Does), and later identified nurses/midwife including Florita Ballano and other nurses impleaded.
- Plaintiffs’ allegations: negligence by Drs. Ramos and Santos for failure to detect a heart condition and to refer for cardiology clearance and to provide appropriate perioperative management; negligence of nurses for failing promptly to give oxygen; hospital negligence for not making oxygen unit available and accessible on the floor.
- Reliefs originally prayed for by plaintiffs: actual damages P814,645.80; compensatory damages P3,416,278.40; moral damages P5,000,000; exemplary damages P2,000,000; attorney’s fees P500,000; P5,000 per hearing and costs of suit; other just and equitable reliefs.
Defenses and Position of Defendants
- Our Lady of Lourdes Hospital and nurses (including Ballano) asserted there was no instruction to place Regina in a room with a standby oxygen tank; they claimed nurses promptly attended to her needs and asked for dismissal and recovery of unpaid medical bills.
- Dr. Miriam Ramos: asserted Regina had never complained of cardiac symptoms during prenatal visits; preoperative exam showed no abnormal cardiac findings; operation was emergency so there was no time to secure cardiac studies or clearance; the cardiopulmonary arrest occurred 14 hours after the operation and long after the doctor had completed surgery; prayed for moral and exemplary damages and attorney’s fees against plaintiffs (counterclaims).
- Dr. Milagros Joyce Santos: described herself as the anesthesiologist for the prior births and as having conducted a preoperative evaluation before the third C‑section showing no cardiovascular or systemic abnormality; administered anesthesia and found Regina stable before, during, and after the operation; prayed for dismissal.
Pleadings, Amendments and Trial Evidence
- Initial complaint filed 24 February 1998 as Civil Case No. MC‑98‑149; summons service on some nurses proved unsuccessful because they no longer worked at the hospital.
- Plaintiffs presented expert and lay witnesses including Dr. Erwin Dizon (cardiologist), Dr. Godfrey Robeniol (neurologist), Mrs. Elizabeth Tayag, Dr. Eleonor Lopez (cardiologist), Kathleen Lucero Balad, Romeo Capanzana, and Dr. Asuncion Ranezes.
- After plaintiffs rested, they amended and impleaded specific nurses on duty (including Czarina Ocampo, H.R. Bolatete, Evelyn S. David, Angelica Concepcion; later further amended to implead Rochelle Padolina and Florita Ballano while dropping some others).
- Defense witnesses included Dr. Santos, Dr. Ramos, Atty. Nicolas Lutero III (DOH Bureau of Licensing and Facilities), Lourdes H. Nicolas (assistant nursing service director), Dr. Grace de los Angeles (resident), Ma. Selerina Cuvin (accounts receivable clerk), and Milagros de Vera (administrative supervisor).
- Petitioner filed a Motion for Leave dated 20 December 2004 to take the deposition of nurse Evelyn David; the trial court denied the Motion in an Order dated 12 April 2005.
Ruling of the Regional Trial Court (RTC)
- Decision rendered 29 December 2006.
- RTC findings regarding doctors: neither Dr. Ramos nor Dr. Santos were negligent; medical standard practices were observed; the primary cause of Regina’s vegetative state was concluded to be amniotic fluid embolism, an unpredictable condition not within doctors’ control to anticipate or prevent.
- RTC findings regarding nurses: although amniotic fluid embolism was root cause of pulmonary edema and subsequent cardiopulmonary arrest, hypoxic encephalopathy was manageable and might have been prevented or minimized by timely administration of oxygen; based on Balad’s testimony, nurses delayed (approximately 10 minutes) before checking the patient, calling the resident doctor and requesting oxygen; expert testimony opined the delay contributed to hypoxic encephalopathy and that timely oxygen would have lessened or avoided brain damage — RTC found contributory negligence on part of the nurses.
- RTC findings regarding hospital responsibility: hospital discharged its burden of proving it exercised the diligence of a good father of a family in selection and supervision of employees based on testimony of assistant nursing director Lourdes Nicolas describing rigorous hiring, orientation, training, on‑the‑job observation and evaluation, supervision by head/charge nurses and inspection by clinical supervisor and nursing director; consequently only the nurse defendant over whom the court had jurisdiction — Florita Ballano (later shown to be a midwife) — was held liable.
- RTC disposition (excerpted): ordered Florita Ballano to pay plaintiffs specified amounts as actual damages, moral damages, compensatory damages, attorney’s fees and costs; dismissed the case as against Our Lady of Lourdes Hospital, Dr. Miriam Ramos and Dr. Milagros Joyce Santos; counterclaims dismissed.
Appeal and Issues Raised
- Respondents (spouses Capanzana) appealed to the Court of Appeals (CA), arguing RTC erred in concluding amniotic fluid embolism (rather than an undetected rheumatic mitral stenosis) caused the cardiopulmonary arrest and brain damage, and that Drs. Ramos and Santos and the hospital were incorrectly absolved.
- Petitioner hospital also appealed, contending: plaintiffs failed to prove any breach by nurses (particularly Ballano); there was no delay in oxygen delivery; Regina’s condition was due to amniotic fluid embolism which could not have been foreseen or prevented; asserted error in dismissal of counterclaims and exclusion of testimony of a hospital nurse.
- Petitioner sought remand to admit testimony (deposition) of nurse Evelyn David and sought relief on unpaid hospital bill and procedural exclusions.
Court of Appeals (CA) Ruling and Reasoning
- CA rendered a decision affirming the RTC with modification.
- CA’s principal factual/legal conclusions:
- Proximate cause of Regina’s vegetative state was hypoxic encep