Professional Services vs. AganaGR No. 126297

Topic: Negligence – Standard of Conduct – Medical Professionals

Facts:

Natividad Agana was rushed to Medical City Hospital because of difficulty of bowel movement and bloody anal discharge. Dr. Ampil diagnosed her to be suffering from "cancer of the sigmoid." Dr. Ampil performed an anterior resection surgery on Natividad. He found that the malignancy in her sigmoid area had spread on her left ovary, necessitating the removal of certain portions. Dr. Ampil obtained the consent of Natividad’s husband, Enrique Agana, to permit Dr. Juan Fuentes, to perform hysterectomy on her.

After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed the operation and closed the incision. However, the operation appeared to be flawed. In the Record of Operation, the attending nurses remarked 2 sponges were missing despite “diligent” search.

Natividad was released but after a couple of days she complained of excruciating pain in her anal region. She consulted both Dr. Ampil and Dr. Fuentes about it. They told her that the pain was the natural consequence of the surgery. Dr. Ampil then recommended that she consult an oncologist to examine the cancerous nodes which were not removed during the operation.

Natividad went to the US for further treatment. After four months Natividad was told she was free of cancer. Natividad returned but was still suffering from pains. Two weeks thereafter, her daughter found a piece of gauze protruding from her vagina. Dr. Ampil went to her house where he extracted by hand a piece of gauze measuring 1.5 inches in width. He then assured her that the pains would soon vanish.

Instead, the pains intensified, prompting Natividad to seek treatment at the Polymedic General Hospital. Dr. Gutierrez detected a foul-smelling gauze measuring 1.5 inches in width in her vagina which badly infected her vaginal vault. A recto-vaginal fistula had formed in her reproductive organs which forced stool to excrete through the vagina. Natividad underwent another surgery.

Natividad and her husband sued Professional Services, Inc. (PSI), owner of the Medical City Hospital, Dr. Ampil, and Dr. Fuentes. They alleged that the latter are liable for negligence for leaving two pieces of gauze inside Natividad’s body and malpractice for concealing their acts of negligence.

Meanwhile, Enrique Agana also filed with the Professional Regulation Commission (PRC) an administrative complaint for gross negligence and malpractice against Dr. Ampil and Dr. Fuentes.

Pending the outcome of the cases, Natividad died and was duly substituted by her above-named children (the Aganas).

Issue:

Was Dr. Ampil negligent in his operation? Can Dr. Fuentes also be held for negligence under res ipsa loquitur?

Held & Rationale:

Ampil was negligent but Fuentes was absolved.

The removal of all sponges used is part of a surgical operation. When a physician or surgeon fails to remove a sponge he has placed in his patient’s body that should be removed as part of the operation, he thereby leaves his operation uncompleted. Ampil created a new condition which imposed the legal duty of calling the new condition to his patient’s attention.

Ampil did not inform Natividad about the missing two pieces of gauze. Worse, he even misled her that the pain she was experiencing was the ordinary consequence of her operation. Had he been more candid, Natividad could have taken the immediate and appropriate medical remedy to remove the gauzes from her body. What was initially an act of negligence by Dr. Ampil has ripened into a deliberate wrongful act of deceiving his patient.

This is a clear case of medical malpractice or more appropriately, medical negligence. To successfully pursue this kind of case, a patient must only prove that a health care provider either failed to do something which a reasonably prudent health care provider would have done, or that he did something that a reasonably prudent provider would not have done; and that failure or action caused injury to the patient. Simply put, the elements are duty, breach, injury and proximate causation. Dr, Ampil, as the lead surgeon, had the duty to remove all foreign objects, such as gauzes, from Natividad’s body before closure of the incision. When he failed to do so, it was his duty to inform Natividad about it. Dr. Ampil breached both duties. Such breach caused injury to Natividad, necessitating her further examination by American doctors and another surgery. Dr. Ampil’s negligence is the proximate cause of Natividad’s injury because he closed the incision despite the attending nurses’ remark that two pieces of gauze

were still missing. That they were later on extracted from Natividad’s vagina established the causal link between Dr. Ampil’s negligence and the injury. His deliberate concealment of the missing gauzes from the knowledge of Natividad and her family further aggravated the injury.

Literally, res ipsa loquitur means "the thing speaks for itself." It is the rule that the fact of the occurrence of an injury, taken with the surrounding circumstances, may permit an inference or raise a presumption of negligence, or make out a plaintiff’s prima facie case, and present a question of fact for defendant to meet with an explanation. Stated differently, where the thing which caused the injury, without the fault of the injured, is under the exclusive control of the defendant and the injury is such that it should not have occurred if he, having such control used proper care, it affords reasonable evidence, in the absence of explanation that the injury arose from the defendant’s want of care, and the burden of proof is shifted to him to establish that he has observed due care and diligence.

From the foregoing statements of the rule, the requisites for the applicability of the doctrine of res ipsa loquitur are: (1) the occurrence of an injury; (2) the thing which caused the injury was under the control and management of the defendant; (3) the occurrence was such that in the ordinary course of things, would not have happened if those who had control or management used proper care; and (4) the absence of explanation by the defendant. Of the foregoing requisites, the most instrumental is the “control and management of the thing which caused the injury.”

The element of "control and management of the thing which caused the injury" is lacking. Hence, the doctrine of res ipsa loquitur will not apply.

Dr. Ampil was the lead surgeon. Dr. Fuentes’ assistance was only for hysterectomy. Dr. Fuentes performed the surgery and showed his work to Dr. Ampil. The latter examined it and finding everything to be in order, allowed Dr. Fuentes to leave the operating room. Dr. Ampil then resumed operating on Natividad. Dr. Fuentes was no longer in the operating room and had, in fact, left the hospital when the injury happened.

Under the "Captain of the Ship" rule, the operating surgeon is the person in complete charge of the surgery room and all personnel connected with the operation. Their duty is to obey his orders. Dr. Ampil was the lead surgeon. He was the "Captain of the Ship." That he discharged such role is evident from his following conduct: (1) calling Dr. Fuentes to perform a hysterectomy; (2) examining the work of Dr. Fuentes and finding it in order; (3) granting Dr. Fuentes’ permission to leave; and (4) ordering the closure of the incision. The closure of the incision notwithstanding two pieces of gauze remained unaccounted for, caused injury to

Natividad’s body. Clearly, the control and management of the thing which caused the injury was in the hands of Dr. Ampil, not Dr. Fuentes.

In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence, does not per se create or constitute an independent or separate ground of liability, being a mere evidentiary rule. In other words, mere invocation and application of the doctrine does not dispense with the requirement of proof of negligence. Here, the negligence was proven to have been committed by Dr. Ampil and not by Dr. Fuentes.

Note:

The rest of the case talked about corporate negligence. I didn’t include since we are focusing on medical professionals. Anyway, the difference of this case to Cruz vs. CA is that the doctor’s negligence seems to have been proved. The case doesn’t say if witness testimony was offered so perhaps it’s safe to assume to say maybe there was.

If not, then the negligence is not so much on the operation, since it was a success. But it would lie on the failure to search for the missing gauzes. And to make it worse, is the misleading action of not telling about that failure to the patient.

Standard of conduct here applies to the “captain” rule.