Case Summary (G.R. No. 130547)
Key Dates and Procedural Posture
Relevant dates: patient’s death on January 9, 1987; complaint for damages filed June 3, 1987; amended complaint September 24, 1987; trial court decision absolving respondents dated September 12, 1991; Court of Appeals affirmance on July 31, 1997; Supreme Court decision denying the petition on October 3, 2000. Procedurally, petitioners’ malpractice action was dismissed by the Regional Trial Court, affirmed by the Court of Appeals, and the petition to the Supreme Court contested those rulings.
Underlying Facts and Clinical Presentation
Jorge Reyes suffered recurring fever with chills for five days prior to admission. On January 8, 1987 he was taken to Mercy Community Clinic, where Dr. Marlyn Rico examined him and noted that he was conscious, ambulatory, oriented, coherent, but exhibited respiratory distress. Typhoid fever was prevalent in the locality, with the clinic reportedly seeing 15–20 typhoid cases monthly.
Diagnostic Workup and Initial Treatment
Dr. Rico ordered a Widal test and other laboratory studies (blood count, urinalysis, stool exam, malarial smear). The Widal test result, returned about an hour later, was interpreted as positive (1:320) and Dr. Rico suspected typhoid fever. Because her shift ended, she indorsed the patient to Dr. Marvie Blanes, who reviewed history and examination and also suspected typhoid. Dr. Blanes ordered a compatibility (skin) test for chloromycetin, which showed no adverse reaction; she then ordered 500 mg of intravenous chloromycetin at about 9:00 p.m. A second 500 mg dose was given about three hours later, just before midnight.
Clinical Deterioration and Death
At approximately 1:00 a.m. on January 9, 1987, the patient’s temperature rose to 41°C with chills, respiratory distress, nausea, vomiting, and convulsions. Dr. Blanes instituted oxygen, suction, hydrocortisone, and later diazepam (Valium), but the patient developed cyanosis and, at about 2:00 a.m., died. Death was attributed to “Ventricular Arrythmia Secondary to Hyperpyrexia and typhoid fever.”
Plaintiffs’ Claims and Theories of Liability
Petitioners alleged that: (1) the death was not from typhoid fever but from wrongful administration of chloromycetin (either anaphylactic reaction or overdose); (2) respondents acted negligently by hastily relying on the Widal test, misdiagnosing typhoid fever, and administering chloromycetin without sufficient testing of drug compatibility; and (3) the clinic and its directress were negligent in failing to provide adequate facilities and in hiring negligent staff.
Issues Agreed for Trial
During pre-trial the parties limited issues to: (1) whether the death of Jorge Reyes was caused by negligence, carelessness, imprudence, or lack of skill or foresight of defendants; (2) whether Mercy Community Clinic was negligent in hiring its employees; and (3) whether either party was entitled to damages.
Evidence at Trial — Petitioners’ Expert
Petitioners presented Dr. Apolinar Vacalares, Chief Pathologist, who conducted the autopsy. He did not open the skull to examine the brain; he found the gastrointestinal tract grossly normal and concluded the cause of death was “shock undetermined,” which could be due to allergic reaction or chloromycetin overdose. He testified he had limited experience with typhoid cases and had not performed an autopsy on a confirmed typhoid fatality; he had seen few clinical typhoid cases.
Evidence at Trial — Respondents’ Experts
Respondents offered two specialists. Dr. Peter Gotiong, an internal medicine diplomate specializing in microbiology and infectious diseases who had treated over a thousand typhoid cases, testified that a history consistent with typhoid plus a Widal titer of 1:320 supported a diagnosis of typhoid fever and that chloramphenicol (chloromycetin) was the drug of choice. He explained that typhoid can produce toxic effects, including myocarditis and toxic meningitis, and that intestinal hyperplasia (Peyer’s patch changes) can be microscopic. Dr. Ibarra Panopio, a pathologist and clinical pathologist, acknowledged the culture test’s greater reliability but conceded that the Widal test is used diagnostically, that a single Widal test gives a presumptive diagnosis (with greater confidence on repeat testing), and that a 1:320 titer is at the maximum dilution from which a conclusion of typhoid may be drawn; he also agreed that intestinal hyperplasia may be microscopic and that autopsy examination of the brain would be required to detect meningitic changes.
Trial Court and Court of Appeals Rulings
The trial court found respondents not negligent and dismissed the complaint (also dismissing respondents’ counterclaim). The Court of Appeals affirmed the dismissal, concluding petitioners failed to prove negligence and that the evidence supported respondents’ diagnosis and treatment. Petitioners then elevated the matter to the Supreme Court.
Legal Framework for Medical Malpractice Applied
The Court summarized medical malpractice law: malpractice is failure to apply the degree of care and skill ordinarily employed by the profession under similar conditions. The required elements are duty, breach, injury, and proximate causation. Expert testimony is ordinarily essential to establish breach and causation because these questions involve scientific and medical determinations. The Court also discussed the exception under the doctrine of res ipsa loquitur (where the injury itself permits an inference of negligence without expert testimony) and articulated the three requisites for its application as reflected in Ramos v. Court of Appeals and other authorities.
Application of Res Ipsa Loquitur to the Case
The Court rejected petitioners’ claim that res ipsa loquitur applied. It emphasized that res ipsa is to be cautiously applied and is limited to situations where the injury is such that a layperson can, from common knowledge, infer negligence (examples include leaving a foreign object in a surgical field or operating on the wrong part). Here, the patient had a serious illness with five days of fever and chills before medical care — a circumstance in which death within hours of treatment was not extraordinary. The circumstances required medical expert analysis to determine whether treatment or diagnosis was negligent; the fatal outcome alone did not supply the necessary inference of negligence.
Evaluation of Specific Allegations Against Dr. Marlyn Rico (Diagnosis)
On the alleged hurried and erroneous diagnosis by Dr. Rico based on a Widal test, the Court found petitioners’ expert (Dr. Vacalares) not qualified to rebut the respondents’ specialists because he lacked experience in infectious diseases and admitted little experience with typhoid cases and autopsy findings in confirmed typhoid deaths. By contrast, respondents’ experts (particularly Dr. Gotiong) were experienced in typhoid diagnosis and treatment and supported Dr. Rico’s use of the Widal test given the clinical history and the local prevalence of typhoid. The Court concluded Dr. Rico did not depart from the reasonable standard of care.
Evaluation of Specific Allegations Against Dr. Marvie Blanes (Chloromycetin Administration)
Regarding the administration and timing of chloromycetin doses, the Court accepted medical authority showing chloramphenicol as an accepted treatment for typhoid and that the dosages and intravenous route used were within medically acceptable limits (noting a recommended dose reference of one gram every six hours). The Court rejected assertions that the second 500 mg dose given about three hours after the
...continue readingCase Syllabus (G.R. No. 130547)
Procedural History
- Petition for review to the Supreme Court from the Court of Appeals decision in CA-G.R. CV No. 36551 affirming the Regional Trial Court, Branch IX, Cebu City.
- Trial court dismissed petitioners' complaint for damages against respondents on September 12, 1991.
- Court of Appeals affirmed the trial court’s dismissal on July 31, 1997.
- Petitioners filed this Supreme Court petition (G.R. No. 130547), decision rendered October 03, 2000; reported 396 Phil. 87; 98 OG No. 5, 630 (February 4, 2002).
- Petition denied and the Court of Appeals decision affirmed by the Supreme Court. Opinion authored by Justice Mendoza; Justices Bellosillo (Chairman), Quisumbing, Buena, and De Leon, Jr., concurred.
Parties
- Petitioners: Leah Alesna Reyes (representing herself and as mother/representative of children Rose Nahdja, Johnny, Lloyd, and Kristine Reyes).
- Respondents: Sisters of Mercy Hospital (Mercy Community Clinic), Sister Rose Palacio (directress), Dr. Marvie Blanes, Dr. Marlyn Rico. Nurse Josephine Pagente originally impleaded but later dropped from amended complaint.
Facts — Pre-Admission and Presentation
- Jorge Reyes (husband of Leah Alesna Reyes) suffered recurring fever with chills for five days prior to admission and failed to obtain relief from home medication consisting of analgesic, antipyretic, and antibiotics.
- On January 8, 1987, Jorge was taken to Mercy Community Clinic and was attended by Dr. Marlyn Rico (resident and admitting physician).
- On admission Jorge was conscious, ambulatory, oriented, coherent, but with respiratory distress.
- Typhoid fever was prevalent locally; the clinic was receiving approximately 15 to 20 typhoid cases per month.
Diagnostic Tests and Initial Clinical Impression
- Dr. Marlyn Rico ordered a Widal Test (standard test for typhoid), blood count, routine urinalysis, stool examination, and malarial smear.
- Medical technician returned test results after about an hour; Dr. Rico concluded Jorge tested positive for typhoid fever.
- Dr. Rico’s shift ended at 5:00 p.m.; she indorsed the patient to Dr. Marvie Blanes.
Treatment Management and Timeline
- Dr. Marvie Blanes attended Jorge at around 6:00 p.m., took history, and performed physical examination; her impression also was typhoid fever.
- Dr. Blanes ordered a compatibility (skin) test with chloromycetin; nurse Josephine Pagente administered the test and gave a dose of triglobe.
- No adverse reaction observed from the skin test; first dose of chloromycetin 500 mg was administered at around 9:00 p.m.
- A second 500 mg dose was administered about three hours later, just before midnight.
- At about 1:00 a.m. on January 9, 1987, Jorge’s temperature rose to 41°C; he experienced chills, respiratory distress, nausea, vomiting, convulsions.
- Dr. Blanes applied oxygen, used suction, administered hydrocortisone, temporarily eased convulsions; patient regained consciousness and denied prior heart ailment.
- Approximately 15 minutes later convulsions returned; valium administered; patient did not respond, developed cyanosis and by around 2:00 a.m. died. He was 40 years old.
- Cause of death recorded as “Ventricular Arrythemia Secondary to Hyperpyrexia and typhoid fever.”
Pleadings, Amended Complaint, and Theories of Liability
- Petitioners filed a complaint for damages on June 3, 1987 against Sisters of Mercy, Sister Rose Palacio, Drs. Blanes and Rico, and nurse Pagente.
- Amended complaint (Sept 24, 1987) impleaded Mercy Community Clinic as additional defendant and dropped Pagente.
- Petitioners’ principal contention: Jorge did not die of typhoid fever but from wrongful administration of chloromycetin; alleged negligent reliance on Widal test, hasty diagnosis, and administration of chloromycetin without sufficient compatibility testing; clinic and directress charged with negligent hiring and inadequate facilities.
Issues Framed at Pre-Trial
- Parties agreed to limit issues to:
- Whether Jorge’s death was due to negligence, carelessness, imprudence, or lack of skill or foresight on the part of defendants;
- Whether Mercy Community Clinic was negligent in hiring its employees;
- Whether either party was entitled to damages.
Evidence at Trial — Petitioners’ Expert
- Petitioners offered Dr. Apolinar Vacalares, Chief Pathologist at Northern Mindanao Training Hospital, who performed autopsy on Jorge on January 9, 1987.
- Dr. Vacalares did not open the skull to examine the brain during autopsy.
- His autopsy findings showed a normal gastro-intestinal tract without ulceration or enlargement of nodules.
- He concluded Jorge did not die of typhoid fever and testified that he had not seen a patient die of typhoid fever within five days from onset.
- Dr. Vacalares admitted limited experience with typhoid: had treated about three typhoid cases and had not previously performed an autopsy on a typhoid victim.
Evidence at Trial — Respondents’ Experts
- Dr. Peter Gotiong: diplomate in internal medicine sp