Case Summary (G.R. No. 235965-66)
Key Dates and Procedural Posture
Admission and transfer to EDH: June 9, 2009.
Debridement and postoperative care: June 10, 2009; death pronounced the same day at 7:00 p.m.
Trial court (RTC) decision dismissing complaint: April 29, 2015; motion for reconsideration denied July 30, 2015.
Court of Appeals decision finding Reyno and De Vera liable: June 28, 2016; CA resolution denying reconsideration: September 20, 2016.
Supreme Court disposition: petition for review on certiorari under Rule 45 denied (affirming CA), applying the 1987 Constitution as the governing charter.
Applicable Law and Doctrines
Constitutional basis: 1987 Philippine Constitution (per instruction to use post‑1990 constitution).
Rules and procedural provisions referenced: Rule 45, Rules of Court (for petition for review); Section 5, Rule 15 of the 1997 Rules on Civil Procedure (notice of hearing for motions); Amended Rules (A.M. No. 19‑10‑20‑SC) making hearings on motions discretionary (Section 6, Rule 15).
Evidentiary and substantive doctrines: res ipsa loquitur as a mode of proof in negligence cases; death certificates as prima facie evidence (Philam Life); procedural due process principles as developed in Jehan Shipping and subsequent jurisprudence (liberal construction where party had opportunity to be heard).
Factual Summary Relevant to Liability
Teresita, a diabetic patient, was referred to EDH for a routine debridement and had pre‑ and post‑operative orders from Dr. De Guzman and Dr. Malvar requiring insulin administration at prescribed times (6:00 a.m., 12:00 n.n., 6:00 p.m., 12:00 m.n.) conditioned upon a Random Blood Sugar (RBS) test prior to each injection. Nurses’ shifts: Gigi Tomas (12:00 m.n.–8:90 a.m.), De Vera (8:00 a.m.–4:00 p.m.), Reyno (4:00 p.m.–12:00 m.n.). De Vera administered insulin at 11:30 a.m.; Reyno administered insulin at 5:20 p.m. Medical records indicate no RBS tests were recorded prior to those injections. After removal and later reapplication of an oxygen mask, Teresita deteriorated, salivated, became unresponsive despite resuscitative efforts, and was pronounced dead at 7:00 p.m. Plaintiffs alleged negligence by EDH staff caused death and sued the LGU Isabela, EDH officers and staff, including nurses Reyno and De Vera.
Trial Court Findings
The RTC dismissed the complaint for lack of merit, principally because (1) the precise cause of death was not conclusively established in the absence of an autopsy, and (2) the court found no negligence on the part of EDH staff: the resident physician responded appropriately in an emergency; nurses acted within their duties, obtained clearance for oxygen removal, and responded when deterioration occurred; and any failure to endorse or perform an RBS test was not shown to be causally linked to the death. The RTC also relieved LGU and Dr. Ventura from liability.
Court of Appeals Holding
The CA partially granted the plaintiffs’ appeal, exonerating LGU, Dr. Ventura, and Dr. Caramancion, but holding nurses Reyno and De Vera jointly and severally liable. The CA applied the doctrine of res ipsa loquitur because: (1) death occurred less than 24 hours after a minor, uncomplicated debridement (an outcome not ordinarily expected), (2) the nurses had exclusive control of the patient’s post‑operative care and failed to comply with clear physician orders (insulin only after RBS testing), and (3) hospital records showed insulin was given without RBS testing and that the patient was kept fasting contrary to instructions—circumstances consistent with hypoglycemia as a plausible cause of death. Damages awarded by the CA (and later affirmed) included actual, civil indemnity, moral, exemplary damages, and attorney’s fees.
Issues Presented to the Supreme Court
- Whether the CA erred in finding that the plaintiffs’ motion for reconsideration in the RTC substantially complied with procedural due process despite lacking a notice of hearing.
- Whether the CA erred in applying res ipsa loquitur to find Reyno and De Vera negligent and causally responsible for Teresita’s death.
Supreme Court: Procedural Due Process Analysis
The Court upheld the CA’s view that the absence of a notice of hearing in the motion for reconsideration did not automatically render the motion void where the opposing party had the opportunity to be heard. The Court relied on Jehan Shipping and subsequent decisions endorsing a pragmatic, liberal construction of procedural rules: the operative test is whether the adverse party had a meaningful opportunity to study and oppose the motion. Records showed petitioners filed comments/oppositions in the RTC and again upon appeal, thereby demonstrating they were not deprived of participation. The Court also noted that the Amended Rules make hearings on motions discretionary, further diminishing the fatality of a missing notice in the procedural context.
Supreme Court: Doctrine of Res Ipsa Loquitur — Legal Standard
The Court recalled the established elements necessary to invoke res ipsa loquitur: (1) the accident is of a character that ordinarily does not occur in the absence of negligence; (2) the instrumentality or agency that caused the accident was under the exclusive control or management of the defendant; and (3) the injury was not due to any voluntary action or contribution by the injured party. The Court emphasized that res ipsa loquitur is a mode of proof that shifts the evidentiary burden to the defendant to explain absence of negligence and that in medical negligence cases the doctrine addresses circumstances where direct proof is not readily available.
Supreme Court: Application of Res Ipsa Loquitur to the Facts
The Court found all three elements satisfied: (1) death following an uncomplicated debridement is an outcome not normally expected; (2) after surgery the patient’s post‑operative care—including administration of medicines and performance of RBS tests—was under the exclusive management of the ward nurses (petitioners); and (3) the decedent did not contribute to her death and was dependent on the nurses for postoperative care. The Court concluded that, given those circumstances, the inference of negligence was warranted absent an adequate explanation.
Evidence Establishing Negligence and Causation
The Court relied on: (a) the Certificate of Death, which listed metabolic encephalopathy versus myocardial infarction and antecedent/underlying probable hypoglycemia (treated as prima facie evidence unless rebutted); (b) Dr. Malvar’s testimony that the nurses administered insulin without conducting the required RBS tests, that such practice exposes a diabetic patient to life‑threatening hypoglycemia, and that the temporal sequence of insulin injections without RBS corresponded to the patient’s rapid d
...continue readingCase Syllabus (G.R. No. 235965-66)
Title and Nature of the Case
- Petition for Review on Certiorari under Rule 45 of the Rules of Court challenging the Court of Appeals (CA) Decision dated June 28, 2016 and Resolution dated September 20, 2016 in CA-G.R. CV No. 105915.
- Petitioners: Eleanor Reyno and Elsa De Vera (nurses).
- Respondents/Plaintiffs: George Baltazar and Joel Baltazar (husband and son of the deceased patient, Teresita Laurena Baltazar).
- Subject matter: Alleged medical negligence leading to the death of Teresita Baltazar; challenge to CA’s finding of joint and several liability of petitioners and attendant procedural arguments regarding notice of hearing on motion for reconsideration.
Antecedents — Parties and Medical Context
- Deceased patient: Teresita Laurena Baltazar, diabetic, under the care of Dr. Jade P. Malvar (attending physician).
- Initial treating facility and referring physician: Dr. Malvar held clinic hours at Callang’s General Hospital (CGH) and referred Teresita to Echague District Hospital (EDH) for debridement due to financial constraints.
- Specialist consulted: Dr. Cabucana De Guzman (specialist in diabetes mellitus) who issued specific orders on insulin administration and random blood sugar (RBS) testing.
- Nurses on duty and shifts:
- Gigi Tomas — ward nurse 12:00 m.n. to 8:00 a.m.
- Elsa De Vera — ward nurse 8:00 a.m. to 4:00 p.m.
- Eleanor Reyno — ward nurse 4:00 p.m. to 12:00 m.n.
- Other medical personnel: anesthesiologist Dr. Baby Delfin L. Cabansag; resident physician on duty Dr. Honorio I. Caramancion; officer-in-charge of EDH Dr. Ma. Cristina A. Ventura; employer: local government unit (LGU), province of Isabela.
Preoperative and Postoperative Orders and Protocols
- Dr. De Guzman’s instructions required insulin administration at scheduled times — specifically noted as 6:00 a.m., 12:00 n.n., 6:00 p.m., and 12:00 m.n. — and required that a Random Blood Sugar (RBS) test be done prior to each insulin injection.
- Post-operative orders recorded by Dr. Malvar included monitoring of vital signs, continuing oral and IV medications, allowing the patient to eat when fully awake, administering insulin "as ordered," and specific frequency of vital sign checks (every 15 minutes for two hours, then every four hours).
- Responsibility for carrying out those orders was assigned to the nurses on ward duty; nurses were expected to record compliance in nurses’ notes.
Timeline of Events (June 9–10, 2009) — Clinical Facts
- June 9, 2009, between 8:00 p.m. and 9:00 p.m.: Teresita transferred to EDH per Dr. Malvar’s written orders for scheduled debridement the next day.
- June 10, 2009:
- 10:30 a.m.: George and Joel visited Teresita; patient appeared in high spirits.
- 11:15 a.m.: Tomas endorsed Teresita to De Vera.
- 11:30 a.m.: De Vera administered insulin to Teresita.
- Approximately 12:20 n.n.: Debridement performed by Dr. Malvar and anesthesiologist Dr. Cabansag; procedure ended without complications.
- Post-operation: Teresita assigned to the ward to recover while De Vera was still on duty.
- 4:00 p.m.: De Vera’s shift ended; she endorsed care to Reyno.
- 5:00 p.m.: Joel visited his mother.
- 5:20 p.m.: Reyno administered insulin to Teresita.
- Approximately one hour after 5:20 p.m.: Reyno removed Teresita’s oxygen mask — she later sought Dr. Cabansag’s permission because of alleged shortage of oxygen masks.
- Shortly after removal: Teresita began having difficulty breathing; Reyno reattached the oxygen mask upon first notification but breathing difficulty and salivation persisted.
- Reyno called Dr. Malvar and, later, Dr. Caramancion (resident physician) to assist; Dr. Malvar instructed a "fifty-fifty intravenous."
- Dr. Caramancion administered epinephrine as an emergency measure, found patient unresponsive, and declared her dead; Dr. Malvar arrived and attempted resuscitation but Teresita was pronounced dead at 7:00 p.m.
Plaintiffs’ Allegations and Relief Sought
- George and Joel alleged negligence on part of EDH personnel, including nurses Reyno and De Vera, resulting in Teresita’s death.
- Defendants named: LGU, province of Isabela (employer of EDH personnel); Dr. Ma. Cristina A. Ventura (officer-in-charge); Dr. Honorio I. Caramancion; and nurses Reyno and De Vera.
- Relief sought: damages for wrongful death and related claims.
Trial Court (RTC) Ruling — April 29, 2015
- RTC dismissed the complaint for lack of merit and made no other pronouncements.
- RTC reasoning:
- The exact cause of Teresita’s death was not clearly established because no autopsy was performed.
- There was no proven negligence on part of EDH personnel.
- Dr. Caramancion (resident) was not the attending physician for the debridement, was not involved in the procedure, and responded promptly to an emergency; thus, he could not be held liable.
- Reyno was found to have ensured vital signs were stable prior to removing the oxygen mask and had prior clearance from Dr. Cabansag; she promptly reattached oxygen upon deterioration and kept Dr. Malvar informed.
- De Vera had properly endorsed the patient to Reyno; even assuming she failed to endorse the need for an RBS test, there was no proof such failure caused death.
- Dr. Ventura was excused from liability for being away on official business but conducted an immediate investigation.
- LGU Isabela was relieved from liability because the cause of death was not established and thus the presumption of employer fault did not arise.
Procedural Posture After RTC Decision
- Plaintiffs filed a motion for reconsideration (June 26, 2015) which the RTC denied by Order dated July 30, 2015.
- Plaintiffs appealed to the Court of Appeals.
Court of Appeals Decision — June 28, 2016
- CA partially granted the appeal:
- Affirmed RTC insofar as LGU Isabela, Dr. Ventura, and Dr. Caramancion were concerned (they were relieved from liability).
- Declared nurses Eleanor Reyno and Elsa De Vera jointly and severally liable to pay respondents:
- Actual damages: P28,690.00
- Civil indemnity: P50,000.00
- Moral damages: P200,000.00
- Exemplary damages: P100,000.00
- Attorney’s fees: P50,000.00
- CA’s principal legal basis: application of the doctrine of res ipsa loquitur to find petitioners negligent and causally connected to Teresita’s death.
CA’s Factual and Legal Findings Supporting Res Ipsa Loquitur
- Chronology and causal nexus:
- Teresita died less than 24 hours after admission and after a minor, uncomplicated debridement — death would not ordinarily follow such procedure absent negligence.
- Hospital records showed insulin was injected without RBS testing as required by doctors’ preoperative orders, exposing patient to hypoglycemia risk.
- Teresita had not been given food since the day before operation, contrary to doctors’ instructions, aggravating risk.
- Doctors’ orders were clear and under exclusive control of the nurses on duty; the nurses had exclusive management of the patient during the period in which deterioration occurred.
- CA concluded the totality of circumstances warranted invoking res ipsa loquitur and shifting burden to petitioners to explain the absence of RBS tests and administration of insulin.