188 SUPREME COURT REPORTS ANNOTATED or surgeon has exercised the requisite degree of skill and care in the

rcised the requisite degree of skill and care in the treatment of

his patient is, in the generality of cases, a matter of expert opinion.All three
Cruz vs. Court of Appeals courts below bewail the inadequacy of the facilities of the clinic and its untidiness;
G.R. No. 122445. November 18, 1997.* the lack of provisions such as blood, oxygen, and certain medicines; the failure to
DR. NINEVETCH CRUZ, petitioner, vs. COURT OF APPEALS and LYDIA subject the patient to a cardio-pulmonary test prior to the operation; the omission
UMALI, respondents. of any form of blood typing before transfusion; and even the subsequent transfer
of Lydia to the San Pablo Hospital and the reoperation performed on her by the
Physicians; Medical Malpractice; Criminal Law; Reckless petitioner. But while it may be true that the circumstances pointed about by the
Imprudence; Elements.This Court, however, holds differently and finds the courts below seemed beyond cavil to constitute reckless imprudence on the part of
foregoing circumstances insufficient to sustain a judgment of conviction against the surgeon, this conclusion is still best arrived at not through the educated
the petitioner for the crime of reckless imprudence resulting in homicide. The surmises nor conjectures of laymen, including judges, but by the unquestionable
elements of reckless imprudence are: (1) that the offender does or fails to do an knowledge of expert witnesses. For whether a physician or surgeon has exercised
act; (2) that the doing or the failure to do that act is voluntary; (3) that it be the requisite degree of skill and care in the treatment of his patient is, in the
without malice; (4) that material damage results from the reckless imprudence; generality of cases, a matter of expert opinion. The deference of courts to the
and (5) that there is inexcusable lack of precaution on the part of the offender, expert opinion of qualified physicians stems from its realization that the latter
taking into consideration his employment or occupation, degree of intelligence, possess unusual technical skills which laymen in most instances are incapable of
physical condition, and other circumstances regarding persons, time and place. intelligently evaluating. Expert testimony should have been offered to prove that
the circumstances cited by the courts below are constitutive of conduct falling
Same; Same; Same; Evidence; Witnesses; Expert Testimony; Whether or not below the standard of care employed by other physicians in good standing when
a physician has committed an inexcusable lack of precaution in the treatment of performing the same operation. It must be remembered that when the
his patient is to be determined according to the standard of care observed by other qualifications of a physician are admitted, as in the instant case, there is an
members of the profession in good standing under similar circumstances bearing inevitable presumption that in proper cases he takes the necessary precaution and
in mind the advanced state of the profession at the time of treatment or the present employs the best of his knowledge and skill in attending to his clients, unless the
state of medical science; Inasmuch as the causes of the injuries involved in contrary is sufficiently established. This presumption is rebuttable by expert
malpractice actions are determinable only in the light of scientific knowledge, it opinion which is so sadly lacking in the case at bench.
has been recognized that exp ert testimony is usually necessary to support the
conclusion as to causation.Whether or not a physician has committed an Same; Same; Same; Same; Burden of Proof; In litigations involving medical
inexcusable lack of precaution in the treatment of his patient is to be determined negligence, the plaintiff has the burden of establishing the defendants negligence
according to the standard of care observed by other members of the profession in and for a reasonable conclusion of negligence, there must be proof of breach of duty
good standing under similar circumstances bearing in mind the advanced state of on the part of the surgeon as well as a causal connection of such breach and the
the profession at the time of treatment or the present state of medical science. In resulting death of his patient.In litigations involving medical negligence, the
the recent case of Leonila Garcia-Rueda v. Wilfred L. Pascasio, et al., this Court plaintiff has the burden of establishing appellants negligence and for a reasonable
stated that in accepting a case, a doctor in effect represents that, having the conclusion of negligence, there must be proof of breach of duty on the part of the
needed training and skill possessed by physicians and surgeons practicing in the surgeon as well as a causal connection of such breach and the resulting death of
same field, he will employ such training, care and skill in the treatment of his his patient. In Chan Lugay v. St. Lukes Hospital, Inc.,where the attending
patients. He therefore has a duty to use at least the same level of care that any physician was absolved of liability for the death of the complainants wife and
other reasonably competent doctor would use to treat a condition under the same newborn baby, this Court held that: In order that there may be a recovery for an
circumstances. It is in this aspect of medical malpractice that expert testimony is injury, however, it must be shown that the injury for which recovery is sought
essential to establish not only the standard of care of the profession but also that must be the legitimate consequence of the wrong done; the connection between the
the physicians conduct in the treatment and care falls below such standard. negligence and the injury must be a direct and natural sequence of events,
Further, inasmuch as the causes of the injuries involved in malpractice actions unbroken by intervening efficient causes. In other words, the negligence must be
are determinable only in the light of scientific knowledge, it has been recognized the proximate cause of the injury. For, negligence, no matter in what it consists,
that expert testimony is usually necessary to support the conclusion as to cannot create a right of action unless it is the proximate cause of the injury
causation. complained of. And the proximate cause of an injury is that cause, which, in
natural and continuous sequence, unbroken by any efficient intervening cause,
Same; Same; Same; Same; Same; Same; While it may be true that certain produces the injury, and without which the result would not have occurred.
circumstances pointed out by the courts below seemed beyond cavil to constitute (Italics supplied.)
reckless imprudence on the part of the surgeon, such conclusion is still best arrived
at not through the educated surmises nor conjectures of laymen, including judges, Same; Same; Same; Evidence; Damages; While a conviction of a crime
but by the unquestionable knowledge of expert witnesses. For whether a physician requires proof beyond reasonable doubt, only a preponderance of evidence is
required to establish civil liability, thus, even as the Court was not able to render negligence, if there is no pre-existing contractual relation between the parties, is
a sentence of conviction for insufficiency of evidence, the Court is not blind to the called a quasi-delict and is governed by the provisions of this Chapter.
reckless and imprudent manner in which the surgeon carried out her duties. 4 Art. 365. Imprudence and Negligence. Any person who, by reckless

Nevertheless, this Court finds the petitioner civilly liable for the death of Lydia imprudence, shall commit any act which, had it been intentional, would constitute
Umali, for while a conviction of a crime requires proof beyond reasonable doubt, a grave felony, shall suffer the penalty of arresto mayor in its maximum period
only a preponderance of evidence is required to establish civil liability. The to prision correccional in its medium period; if it would have constituted a less
petitioner is a doctor in whose hands a patient puts his life and limb. For grave felony, the
insufficiency of evidence this Court was not able to render a sentence of conviction 193
but it is not blind to the reckless and imprudent manner in which the petitioner VOL. 282, NOVEMBER 18, 1997 193
carried out her duties. A precious life has been lost and the circumstances leading
thereto exacerbated the grief of those left behind. The heirs of the deceased Cruz vs. Court of Appeals
continue to feel the loss of their mother up to the present time and this Court is with which the civil action for damages is impliedly instituted. It is via the latter
aware that no amount of compassion and commiseration nor words of type of action that the heirs of the deceased sought redress for the petitioners
bereavement can suffice to assuage the sorrow felt for the loss of a loved one. alleged imprudence and negligence in treating the deceased thereby caus-
Certainly, the award of moral and exemplary damages in favor of the heirs of
Lydia Umali are proper in the instant case. _______________

PETITION for review on certiorari of a decision of the Court of Appeals. penalty of arresto mayor in its minimum and medium periods shall be
imposed; if it would have constituted a light felony, the penalty, of arresto
The facts are stated in the opinion of the Court. menor in its maximum period shall be imposed.
Tranquilino F. Meris Law Office for petitioner.
The Solicitor General for public respondent. Any person who, by simple imprudence or negligence, shall commit an act
which would otherwise constitute a grave felony, shall suffer the penalty of arresto
FRANCISCO, J.: mayor in its medium and maximum periods; if it would have constituted a less
serious felony, the penalty of arresto mayor in its minimum period shall be
Doctors are protected by a special rule of law. They are not guarantors imposed.
of care. They do not even warrant a good result. They are not insurers against
mishaps or unusual consequences. Furthermore they are not liable for honest When the execution of the act covered by this article shall have only resulted
mistakes of judgment . . .1 in damage to the property of another, the offender shall be punished by a fine
ranging from an amount equal to the value of said damages to three times such
The present case against petitioner is in the nature of a medical value, but which shall in no case be less than twenty-five pesos.
malpractice suit, which in simplest terms is the type of claim which a victim has
available to him or her to redress a wrong committed by a medical professional A fine not exceeding two hundred-pesos and censure shall be imposed upon
which has caused bodily harm.2 In this jurisdiction, however, such claims are most any person who, by simple imprudence or negligence, shall cause some wrong
often brought as a civil action for damages under Article 2176 of the Civil which, if done maliciously, would have constituted a light felony.
Code,3 and in some instances, as a criminal case under Article 365 of the Revised I
Penal Code4 n the imposition of these penalties, the courts shall exercise their sound
discretion, without regard to the rules prescribed in article sixty-four.
The provisions contained in this article shall not be applicable:
________________

1 THE PHYSICIANS LIABILITY AND THE LAW ON NEGLIGENCE by 1. When the penalty provided for the offense is equal to or lower than
Constantino Nuez, p. 1 citing Louis Nizer, My Life in Court, New York: Double those provided in the first two paragraphs of this article, in which case
Day & Co., 1961 in Tolentino, Jr., MEDICINE and LAW, Proceedings of the the courts shall impose the penalty next lower in degree than that which
Symposium on Current Issues Common to Medicine and Law, U.P. Law Center, should be imposed, in the period which they may deem proper to apply.
1980.
2 Leonila Garcia-Rueda vs. Wilfred L. Pascasio, et al., G.R. No. 118141, 2. When, by imprudence or negligence and with violation of the
September 5, 1997. Automobile Law, the death of a person shall be caused, in which case the
3 ART. 2176. Whoever by act or omission causes damage to another, there defendant shall be punished by prision correccional in its medium and
being fault or negligence, is obliged to pay for the damage done. Such fault or the maximum periods.
 Reckless imprudence consists in voluntarily, but without malice, doing or Cruz vs. Court of Appeals
failing to do an act from which material damage results by reason of inexcusable The petitioner appealed her conviction to the Regional Trial Court (RTC)
lack of precaution on the part of the person performing or failing to perform such which affirmed in toto the decision of the MTCC7 prompting the petitioner to file
act, taking into consideration his employment or occupation, degree of a petition for review with the Court of Appeals but to no avail. Hence this petition
intelligence, physical condition and other circumstances regarding persons, time for review on certiorari assailing the decision promulgated by the Court of Appeals
and place. on October 24, 1995 affirming petitioners conviction with modification that she is
further directed to pay the heirs of Lydia Umali P50,000.00 as indemnity for her
194 SUPREME COURT REPORTS ANNOTATED death.8
Cruz vs. Court of Appeals
ing her death. The petitioner and one Dr. Lina Ercillo who was the attending In substance, the petition brought before this Court raises the issue of whether
anaesthesiologist during the operation of the deceased were charged with or not petitioners conviction of the crime of reckless imprudence resulting in
reckless imprudence and negligence resulting to (sic) homicide in an information homicide, arising from an alleged medical malpractice, is supported by the
which reads: evidence on record.

That on or about March 23, 1991, in the City of San Pablo, Republic of First the antecedent facts.
the Philippines and within the jurisdiction of this Honorable Court, the accused
abovenamed, being then the attending anaesthesiologist and surgeon, On March 22, 1991, prosecution witness, Rowena Umali De Ocampo,
respectively, did then and there, in a negligence (sic), careless, imprudent, and accompanied her mother to the Perpetual Help Clinic and General Hospital
incompetent manner, and failing to supply or store sufficient provisions and situated in Balagtas Street, San Pablo City, Laguna. They arrived at the said
facilities necessary to meet any and all exigencies apt to arise before, during hospital at around 4:30 in the afternoon of the same day.9 Prior to March 22, 1991,
and/or after a surgical operation causing by such negligence, carelessness, Lydia was examined by the petitioner who found a myoma 10 in her uterus, and
imprudence, and incompetence, and causing by such failure, including the lack of scheduled her for a hysterectomy operation on March 23, 1991. 11Rowena and her
preparation and foresight needed to avert a tragedy, the untimely death of said mother slept in the clinic on the evening of March 22, 1991 as the latter was to be
Lydia Umali on the day following said surgical operation.5 operated on the next day at 1:00 oclock in the afternoon.12 According to Rowena,
she noticed that the clinic was untidy and the window and the floor were very
Trial ensued after both the petitioner and Dr. Lina Ercillo pleaded not dusty prompting her to ask the attendant for a rag to wipe the window and the
guilty to the above-mentioned charge. On March 4, 1994, the Municipal Trial floor with.13 Because of the untidy state of the clinic, Rowena tried to persuade
Court in Cities (MTCC) of San Pablo City rendered a decision, the dispositive her mother not to proceed with the operation.14 The following day, before her
portion of which is hereunder quoted as follows: mother was wheeled into the operating room, Rowena asked the petitioner if the
operation could be postponed. The petitioner called Lydia into her office and the
WHEREFORE, the court finds the accused Dra. Lina Ercillo not guilty two had a conversation. Lydia then informed Rowena that the petitioner told her
of the offense charged for insufficiency of evidence while her co-accused Dra. that she must be operated on as scheduled.15
Ninevetch Cruz is hereby held responsible for the death of Lydia Umali on March
24, 1991, and therefore guilty under Art. 365 of the Revised Penal Code, and she Rowena and her other relatives, namely her husband, her sister and two aunts
is hereby sentenced to suffer the penalty of 2 months and 1 day imprisonment of waited outside the operating room while Lydia underwent operation. While they
arresto mayor with costs.6 were waiting, Dr. Ercillo went out of the operating room and instructed them to
buy tagamet ampules which Rowenas sister immediately bought. About one hour
had passed when Dr. Ercillo came out again this time to ask them to buy blood for
________________
Lydia. They bought type A blood from the St. Gerald Blood Bank and the same
was brought by the attendant into the operating room. After the lapse of a few
Simple imprudence consists in the lack of precaution displayed in those cases hours, the petitioner informed them that the operation was finished. The
in which the damage impending to be caused is not immediate nor the danger operating staff then went inside the petitioners clinic to take their snacks. some
clearly manifest. thirty minutes after, Lydia was brought out of the operating room in a stretcher
The penalty next higher in degree to those provided for in this article shall be and the petitioner asked Rowena and the other relatives to buy additional blood
imposed upon the offender who fails to lend on the spot to the injured parties such for Lydia.
help as may be in his hands to give.
5 INFORMATION.
6 DECISION in Criminal Case No. 25534, March 4, 1994, p. 12; Rollo, p. 65.
Unfortunately, they were not able to comply with petitioners order as
there was no more type A blood available in the blood bank. Thereafter, a person
195 arrived to donate blood which was later transfused to Lydia. Rowena then noticed
VOL. 282, NOVEMBER 18, 1997 195 her mother, who was attached to an oxygen tank, gasping for breath. Apparently
the oxygen supply had run out and Rowenas husband together with the driver of The RTC reiterated the abovementioned findings of the MTCC and
the accused had to go to the San Pablo District Hospital to get oxygen. Lydia was upheld the latters declaration of incompetency, negligence and lack of foresight
given the fresh supply of oxygen as soon as it arrived.16 But at around 10:00 oclock and skill of appellant (herein petitioner) in handling the subject patient before and
P.M. she went into shock and her blood pressure dropped to 60/50. Lydias after the operation.24 And likewise affirming the petitioners conviction, the
unstable condition necessitated her transfer to the San Pablo District Hospital so Court of Appeals echoed similar observations, thus:
she could be connected to a respirator and further examined.17 The transfer to the
San Pablo District Hospital was without the prior consent of Rowena nor of the x x x. While we may grant that the untidiness and filthiness of the clinic may not
other relatives present who found out about the intended transfer only when an by itself indicate negligence, it nevertheless shows the absence of due care and
ambulance arrived to take Lydia to the San Pablo District Hospital. Rowena and supervision over her subordinate employees. Did this unsanitary condition
her other relatives then boarded a tricycle and followed the ambulance.18 permeate the operating room? Were the surgical instruments properly sterilized?
Could the conditions in the OR have contributed to the infection of the patient?
Upon Lydias arrival at the San Pablo District Hospital, she was wheeled into Only the petitioner could answer these, but she opted not to testify. This could
the operating room and the petitioner and Dr. Ercillo re-operated on her because only give rise to the presumption that she has nothing good to testify on her
there was blood oozing from the abdominal incision.19 The attending physicians defense. Anyway, the alleged unverified statement of the prosecution witness
summoned Dr. Bartolome Angeles, head of the Obstetrics and Gynecology remains unchallenged and unrebutted.
Department of San Pablo District Hospital. However, when Dr. Angeles arrived,
Lydia was already in shock and possibly dead as her blood pressure was already Likewise undisputed is the prosecutions version indicating the following facts:
o/o. Dr. Agneles then informed petitioner and Dr. Ercillo that there was nothing that the accused asked the patients relatives to buy Tagamet capsules while the
he could do to help save the patient.20 While the petitioner was closing the operation was already in progress; that after an hour, they were also asked to buy
abdominal wall, the patient died.21 Thus, on March 24, 1991, at 3:00 oclock in the type A blood for the patient; that after surgery, they were again asked to procure
morning, Lydia Umali was pronounced dead. Her death certificate states shock more type A blood, but such was not anymore available from the source; that the
as the immediate cause of death and Disseminated Intravascular Coagulation oxygen given to the patient was empty; and that the son-in-law of the patient,
(DIC) as the antecedent cause.22 together with a driver of the petitioner, had to rush to the San Pablo City District
Hospital to get the much-needed oxygen. All these conclusively show that the
In convicting the petitioner, the MTCC found the following circumstances as petitioner had not prepared for any unforeseen circumstances before going into
sufficient basis to conclude that she was indeed negligent in the performance of the first surgery, which was not emergency in nature, but was elective or pre-
the operation: scheduled; she had no ready antibiotics, no prepared blood, properly typed and
cross-matched, and no sufficient oxygen supply.
x x x, the clinic was untidy, there was lack of provision like blood and oxygen to
prepare for any contingency that might happen during the operation. The manner Moreover, there are a lot of questions that keep nagging Us. Was the patient
and the fact that the patient was brought to the San Pablo District Hospital for given any cardio-pulmonary clearance, or at least a clearance by an internist,
reoperation indicates that there was something wrong in the manner in which which are standard requirements before a patient is subjected to surgery. Did the
Dra. Cruz conducted the operation. There was no showing that before the petitioner determine as part of the pre-operative evaluation, the bleeding
operation, accused Dra. Cruz had conducted a cardio pulmonary clearance or any parameters of the patient, such as bleeding time and clotting time? There is no
typing of the blood of the patient. It was (sic) said in medical parlance that the showing that these were done. The petitioner just appears to have been in a hurry
the abdomen of the person is a temple of surprises because you do not know the to perform the operation, even as the family wanted a postponement to April 6,
whole thing the moment it was open (sic) and surgeon must be prepared for any 1991. Obviously, she did not prepare the patient; neither did she get the familys
eventuality thereof. The patient (sic) chart which is a public document was not consent to the operation. Moreover, she did not prepare a medical chart with
presented because it is only there that we could determine the condition of the instructions for the patients care. If she did all these, proof thereof should have
patient before the surgery. The court also noticed in Exh. F-1 that the sister of been offered. But there is none. Indeed, these are overwhelming evidence of
the deceased wished to postpone the operation but the patient was prevailed upon recklessness and imprudence.25
by Dra. Cruz to proceed with the surgery. The court finds that Lydia Umali died
because of the negligence and carelessness of the surgeon Dra. Ninevetch Cruz This Court, however, holds differently and finds the foregoing circumstances
because of loss of blood during the operation of the deceased for evident insufficient to sustain a judgment of conviction against the petitioner for the crime
unpreparedness and for lack of skill, the reason why the patient was brought for of reckless imprudence resulting in homicide. The elements of reckless
operation at the San Pablo City District Hospital. As such, the surgeon should imprudence are: (1) that the offender does or fails to do an act; (2) that the doing
answer for such negligence. With respect to Dra. Lina Ercillo, the or the failure to do that act is voluntary; (3) that it be without malice; (4) that
anaesthesiologist, there is no evidence to indicate that she should be held jointly material damage results from the reckless imprudence; and (5) that there is
liable with Dra. Cruz who actually did the operation.23 inexcusable lack of precaution on the part of the offender, taking into
consideration his employment or occupation, degree of intelligence, physical to his clients, unless the contrary is sufficiently established. 32 This presumption
condition, and other circumstances regarding persons, time and place. is rebuttable by expert opinion which is so sadly lacking in the case at bench.

Whether or not a physician has committed an inexcusable lack of precaution Even granting arguendo that the inadequacy of the facilities and untidiness
in the treatment of his patient is to be determined according to the standard of of the clinic; the lack of provisions; the failure to conduct pre-operation tests on
care observed by other members of the profession in good standing under similar the patient; and the subsequent transfer of Lydia to the San Pablo Hospital and
circumstances bearing in mind the advanced state of the profession at the time of the reoperation performed on her by the petitioner do indicate, even without
treatment or the present state of medical science.26 In the recent case of Leonila expert testimony, that petitioner was recklessly imprudent in the exercise of her
Garcia-Rueda v. Wilfred L. Pascasio, et al.,27 this Court stated that in accepting a duties as a surgeon, no cogent proof exists that any of these circumstances caused
case, a doctor in effect represents that, having the needed training and skill petitioners death. Thus, the absence of the fourth element of reckless imprudence:
possessed by physicians and surgeons practicing in the same field, he will employ that the injury to the person or property was a consequence of the reckless
such training, care and skill in the treatment of his patients. He therefore has a imprudence.
duty to use at least the same level of care that any other reasonably competent
doctor would use to treat a condition under the same circumstances. It is in this In litigations involving medical negligence, the plaintiff has the burden of
aspect of medical malpractice that expert testimony is essential to establish not establishing appellants negligence and for a reasonable conclusion of negligence,
only the standard of care of the profession but also that the physicians conduct in there must be proof of breach of duty on the part of the surgeon as well as a causal
the treatment and care falls below such standard. 28 Further, inasmuch as the connection of such breach and the resulting death of his patient.33 In Chan Lugay
causes of the injuries involved in malpractice actions are determinable only in the v. St. Lukes Hospital, Inc., 34 where the attending physician was absolved of
light of scientific knowledge, it has been recognized that expert testimony is liability for the death of the complainants wife and newborn baby, this Court held
usually necessary to support the conclusion as to causation.29 that:

Immediately apparent from a review of the records of this case is the absence In order that there may be a recovery for an injury, however, it must be shown
of any expert testimony of the matter of the standard of care employed by other that the injury for which recovery is sought must be the legitimate consequence
physicians of good standing in the conduct of similar operations. The prosecutions of the wrong done; the connection between the negligence and the injury must be
expert witnesses in the persons of Dr. Floresto Arizala and Dr. Nieto Salvador, Jr. a direct and natural sequence of events, unbroken by intervening efficient
of the National Bureau of Investigation (NBI) only testified as to the possible causes. In other words, the negligence must be the proximate cause of the injury.
cause of death but did not venture to illuminate the court on the matter of the For, negligence, no matter in what it consists, cannot create a right of action unless
standard of care that petitioner should have exercised. it is the proximate cause of the injury complained of. And the proximate cause of
an injury is that cause, which, in natural and continuous sequence, unbroken by
All three courts below bewail the inadequacy of the facilities of the clinic and any efficient intervening cause, produces the injury, and without which the result
its untidiness; the lack of provisions such as blood, oxygen, and certain medicines; would not have occurred.35 (Italics supplied.)
the failure to subject the patient to a cardio-pulmonary test prior to the operation;
the omission of any form of blood typing before transfusion; and even the Dr. Arizala who conducted an autopsy on the body of thedeceased summarized his
subsequent transfer of Lydia to the San Pablo Hospital and the reoperation findings as follows:
performed on her by the petitioner. But while it may be true that the
circumstances pointed out by the courts below seemed beyond cavil to constitute Atty. Cachero:
reckless imprudence on the part of the surgeon, this conclusion is still best arrived
at not through the educated surmises nor conjectures of laymen, including judges,
but by the unquestionable knowledge of expert witnesses. For whether a physician Q. You mentioned about your Autopsy Report which has been marked as Exh. A-1-b.
or surgeon has exercised the requisite degree of skill and care in the treatment of There appears here a signature above the typewritten name Floresto Arizala, Jr.,
his patient is, in the generality of cases, a matter of expert opinion.30 The
deference of courts to the expert opinion of qualified physicians stems from its whose signature is that?
realization that the latter possess unusual technical skills which laymen in most A. That is my signature, sir.
instances are incapable of intelligently evaluating. 31 Expert testimony should Q. Do you affirm the truth of all the contents of Exh. A-1-b?
have been offered to prove that the circumstances cited by the courts below are
constitutive of conduct falling below the standard of care employed by other A. Only as to the autopsy report no. 91-09, the time and place and everything after the
physicians in good standing when performing the same operation. It must be post mortem findings, sir.
remembered that when the qualifications of a physician are admitted, as in the Q. You mentioned on your Post Mortem Findings about surgical incision, 14:0 cm.,
instant case, there is an inevitable presumption that in proper cases he takes the
necessary precaution and employs the best of his knowledge and skill in attending infraumbilical area, anterior abdominal area, midline, will you please explain that in
your own language?
A. There was incision wound (sic) the area just below the navel, sir. A. Unattended hemorrhage, sir.36 (Italics supplied.)
Q. And the last paragraph of the postmortem findings which I read: Uterus, pear-shaped
and pale measuring 7.5 x 5.5 x 5.0 cm. with some surface nodulation of the fundic The foregoing was corroborated by Dr. Nieto Salvador:
area posteriorly. Cut-section shows diffusely pale myometrium with areas of streak
Q. And were you able to determine the cause of death by virtue of the examination
induration. The ovaries and adnexal structures are missing with the raw surfaces
of the specimen submitted by Dr. Arizala?
patched with clotted blood. Surgical sutures were noted on the operative site.
A. Without knowledge of the autopsy findings it would be difficult for me to

Intestines and mesenteries are pale with blood clots noted between the mesentric determine the cause of death, sir.
folds. Q. Have you also examined the post mortem of Dr. Arizala?
Hemoperitoneum: 300 s.s., A. Yes, sir, and by virtue of the autopsy report in connection with your pathology
right paracolic gutter,
50 c.c., left paracolic gutter report.
200 c.c., mesentric area, Q. What could have caused the death of the victim?
100 c.c., right pelvic gutter A. This pathologic examination are (sic) compatible with the person who died, sir.
stomach empty.
Other visceral organs, pale, Q. Will you explain to us the meaning of hemorrhagic compatible?
will you please explain that on (sic) your own language or in ordinary.......... A. It means that a person died of blood loss. Meaning a person died of non-
A. There was a uterus which was not attached to the adnexal structures namely ovaries replacement of blood and so the victim before she died there was shock of
which were not present diminish of blood of the circulation. She died most probably before the actual
and also sign of previous surgical operation and there were (sic) clotted blood, sir. complete blood loss, sir.
Q. How about the ovaries and adnexal structures? Court: Is it possible doctor that the loss of the blood was due on (sic) operation?
A. They are missing, sir. A. Based on my pathologist finding, sir.
Q. You mean to say there are no ovaries? Q. What could have caused this loss of blood?
A. During that time there are no ovaries, sir. A. Many, sir. A patient who have undergone surgery. Another may be a blood vessel
Q. And there were likewise sign of surgical sutures? may be cut while on operation and this cause (sic) bleeding, or may be set in the
A. Yes, sir. course of operation, or may be (sic) he died after the operation. Ofcourse there
Q. How about the intestines and mesenteries are place (sic) with blood clots noted are other cause (sic).
between the mesenteric folds, will you please explain on (sic) this? Atty. Cachero:
A. In the peritoneal cavity, they are mostly perritonial blood......... Q. Especially so doctor when there was no blood replacement?
Q. And what could have caused this blood? A. Yes, sir.37 (underscoring supplied.)
A. Well, ordinarily blood is found inside the blood vessel. Blood were (sic) outside as a
The testimonies of both doctors establish hemorrhage or hemorrhagic shock as the
result of the injuries which destroyed the integrity of the vessel allowing blood to sip cause of death. However, as likewise testified to by the expert witnesses in open
(sic) out, sir. court, hemorrhage or hemorrhagic shock during surgery may be caused by several
Q. By the nature of the postmortem findings indicated in Exh. A-1-B, can you tell the different factors. Thus, Dr. Salvadors elaboration on the matter:
court the cause of death?
Atty. Pascual:
A. Yes, sir. The cause of death is: Gross findings are compatible with hemorrhagic
shock.
Q. Doctor, among the causes of hemorrhage that you mentioned you said that it could
Q. Can you tell to us what could have caused this hemorrhagic shock?
be at the moment of operation when one loses (sic) control of the presence, is that
A. Well hemorrhagic shock is the result of blood loss.
correct? During the operation there is lost (sic) of control of the cut vessel?
Q. What could have the effect of that loss of blood?
A. Yes, sir. Q: Doctor, in examining these structures did you know whether these were sutured
Q. Or there is a failure to ligate a vessel of considerable size? ligature or plain ligature.
A. Yes, sir. A: Ligature, sir.
Q. Or even if the vessel were ligated the knot may have slipped later on? Q: We will explain that later on. Did you recall if the cut structures were tied by first
A. Yes, sir. suturing it and then tying a knot or the tie was merely placed around the cut structure
Q. And you also mentioned that it may be possible also due to some clotting defect, is and tied?
that correct? A: I cannot recall, sir.
A. May be (sic).38
(Italics supplied.) Q: As a matter of fact, you cannot recall because you did not even bothered (sic) to
Defense witness, Dr. Bu C. Castro also gave the following expert opinion: examine, is that correct?
Q. Doctor even a patient after an operations (sic) would suffer hemorrage what would A: Well, I bothered enough to know that they were sutured, sir.
be the possible causes of such hemorrage (sic)? Q: So, therefore, Doctor, you would not know whether any of the cut structures were
A. Among those would be what we call Intravascular Coagulation and this is the not sutured or tied neither were you able to determine whether any loose suture was
reason for the bleeding, sir, which cannot be prevented by anyone, it will happen found in the peritoneal cavity?
to anyone, anytime and to any persons (sic), sir. A: I could not recall any loose sutured (sic), sir.41
COURT:
What do you think of the cause of the bleeding, the cutting or the operations done On the other hand, the findings of all three doctors do not preclude the
probability that DIC caused the hemorrhage and consequently, Lydias death. DIC
in the body? which is a clotting defect creates a serious bleeding tendency and when massive
A. Not related to this one, the bleeding here is not related to any cutting or operation DIC occurs as a complication of surgery leaving raw surface, major hemorrhage
that I (sic) have done. occurs.42 And as testified to by defense witness, Dr. Bu C. Castro, hemorrhage due
to DIC cannot be prevented, it will happen to anyone, anytime. 43 He testified
Q. Aside from the DIC what could another causes (sic) that could be the cause for the further:
hemorrhage or bleeding in a patient by an operations(sic)?
A. In general sir, if there was an operations (sic) and it is possible that the ligature in Q. Now, under that circumstance one of the possibility as you mentioned in (sic) DIC?
the suture was (sic) become (sic) loose, it is (sic) becomes loose if proven. A. Yes, sir.
Q. And you mentioned that this cannot be prevented?
xxx xxx xxx A. Yes, sir.
Q. If the person who performed an autopsy does not find any untight (sic) clot (sic) Q. Can you even predict if it really happen (sic)?
blood vessel or any suture that become (sic) loose the cause of the bleeding could A. Possible, sir.
not be attributed to the fault of the subject? Q. Are there any specific findings of autopsy that will tell you whether this patient
A. Definitely, sir.39 (Italics supplied.) suffered among such things as DIC?
A. Well, I did reserve because of the condition of the patient.
According to both doctors, the possible causes of hemorrhage during an
operation are: (1) the failure of the surgeon to tie or suture a cut blood vessel; (2) Q. Now, Doctor you said that you went through the record of the deceased Lydia Umali
allowing a cut blood vessel to get out of control; (3) the subsequent loosening of the looking for the chart, the operated (sic) records, the post mortem findings on the
tie or suture applied to a cut blood vessel; and (4) and a clotting defect known as histophanic (sic) examination based on your examination of record, doctor, can you
DIC. It is significant to state at this juncture that the autopsy conducted by Dr.
Arizala on the body of Lydia did not reveal any untied or unsutured cut blood more or less says (sic) what part are (sic)concerned could have been the caused (sic)
vessel nor was there any indication that the tie or suture of a cut blood vessel had of death of this Lydia Umali?
become loose thereby causing the hemorrhage.40 Hence the following pertinent portion of Dr. A. As far as the medical record is concern (sic) the caused (sic) of death is dessimulated
Arizalas testimony:
(sic) Intra Vascular Coagulation or the DIC which resulted to hemorrhage or
bleedings, sir.
Q. Doctor based on your findings then there is knowing (sic) the doctor would say
Let a copy of this decision be furnished to the Professional Regulation
whether the doctor her (sir) has been (sic) fault? Commission (PRC) for appropriate action.
ATTY. MALVEDA:
We will moved (sic) to strike out the (sic) based on finding they just read the chart __________________
as well as the other record. 46
ATTY. PASCUAL:
Q. When you came to know that your mother was already dead there in the operating
Precisely based on this examination.
room of the San Pablo District Hospital, how did you feel being the daughter?
ATTY. MALVEDA:
A. I was crying and crying hysterically. And I asked why it happened to my mother, sir.
Not finding, there was no finding made.
Q. And up to the present time do you still feel about the loss of your mother?
COURT:
A. Yes, sir.
He is only reading the record.
Q. How about your sister and brother?
ATTY. PASCUAL:
A. Same with me, sir.
Yes, sir.
Q. Estimated to money value, how much I cost you and your sister and brotherthe
A. No, sir, there is no fault on the part of the surgeon, sir.44
lost of your mother?
A. There is no equivalent, sir. (TSN, Rowena Umali De Ocampo, supra, p. 18.)
This Court has no recourse but to rely on the expert testimonies rendered by
both prosecution and defense witnesses that substantiate rather than contradict
SO ORDERED.
petitioners allegation that the cause of Lydias death was DIC which, as attested
Romero, Melo and Panganiban, JJ., concur.
to by an expert witness, cannot be attributed to the petitioners fault or negligence.
Narvasa (C.J., Chairman), On leave.
The probability that Lydias death was caused by DIC was unrebutted during trial
Petitioner acquitted but ordered to pay moral and exemplary damages.
and has engendered in the mind of this Court a reasonable doubt as to the
petitioners guilt. Thus, her acquittal of the crime of reckless imprudence resulting
Notes.The supposed medical evaluation made by appellant or his counsel,
in homicide. While we condole with the family of Lydia Umali, our hands are
without showing their competence in the field of medicine, must give way to the
bound by the dictates of justice and fair dealing which hold inviolable the right of
expert testimony of the examining physician. (People vs. Pelones, 230 SCRA
an accused to be presumed innocent until proven guilty beyond reasonable doubt.
379 [1994])
Nevertheless, this Court finds the petitioner civilly liable for the death of Lydia
Umali, for while a conviction of a crime requires proof beyond reasonable doubt,
The fact of want of competence or diligence is evidentiary in nature, the
only a preponderance of evidence is required to establish civil liability. 45
veracity of which can best be passed upon after a full-blown trial for it is virtually
impossible to ascertain the merits of a medical negligence case without extensive
The petitioner is a doctor in whose hands a patient puts his life and limb. For
investigation, research, evaluation and consultations with medical experts
insufficiency of evidence this Court was not able to render a sentence of conviction
clearly, the City Prosecutors are not in a competent position to pass judgment on
but it is not blind to the reckless and imprudent manner in which the petitioner
such a technical matter, especially when there are conflicting evidence and
carried out her duties. A precious life has been lost and the circumstances leading
findings. (Garcia-Rueda vs. Pascasio, 278 SCRA 769[1997])
thereto exacerbated the grief of those left behind. The heirs of the deceased
continue to feel the loss of their mother up to the present time46 and this Court is
aware that no amount of compassion and commiseration nor words of o0o
bereavement can suffice to assuage the sorrow felt for the loss of a loved one.
Certainly, the award of moral and exemplary damages in favor of the heirs of
Lydia Umali are proper in the instant case.

WHEREFORE, premises considered, petitioner DR. NINEVETCH CRUZ is

hereby ACQUITTED of the crime of reckless imprudence resulting in homicide
but is ordered to pay the heirs of the deceased Lydia Umali the amount of FIFTY
THOUSAND PESOS (P50,000.00) as civil liability, ONE HUNDRED
THOUSAND PESOS (P100,000.00) as moral damages, and FIFTY THOUSAND
PESOS (P50,000.00) as exemplary damages.