Legal Medicine Reviewer

LEGAL MEDICINE REVIEWER

N E W

Legal Medicine Is that branch of medicine that applies, medical and surgical concepts, scientific knowledge and skills to medico legal issues, in order to assist the trier of facts in the proper dispensation of justice. Medical Jurisprudence is the study of the Medical Law and its applicable Jurisprudence that governs, regulates and defines the practice of medicine. I. INTRODUCTION: THE FILIPINO PHYSICIAN Medical education in the Philippines is principally offered and developed by accredited and government recognized medical schools in the country. The Philippine medical schools are graduate schools offering the Doctor of Medicine (M.D.) degree. The M.D. is a four-year professional degree program which qualifies the degree holder to take the licensure exam for medical doctors in the Philippines. Professional medical degree The Doctor of Medicine (M.D.) is a four-year professional degree program dealing with medical theories, practices, technologies, and problem solving. The completion of the degree program with one-year postgraduate internship qualifies a candidate to take the licensure exam for medical doctors in the Philippines. After becoming a licensed doctor, a Physician may choose to stop there and start earning as a G.P. (general physician), or be a residence doctor or take a speciality in a field he or she wants which will take almost 4-5 years (for training.) Admission to medical schools Before applying to any medical school, a candidate must earn a bachelor's degree with credits in certain required subjects. The most common pre-medical degrees include biology, pharmacy, medical technology, biochemistry, nursing, and physical therapy. In addition, a candidate must take the National Medical Admission Test (NMAT), the national entrance exam for all medical schools in the Philippines. PRACTICE OF MEDICINE 1. PRC vs De Guzman (G.R. No. 144681, June 21, 2004) DOCTRINE: Until the moral and mental fitness of the respondents could be ascertained, according to petitioners, the Board has discretion to hold in abeyance the administration of the Hippocratic Oath and the issuance of the certificates to them. The writ of mandamus does not lie to compel performance of an act which is not duly authorized. The respondents nevertheless argue that under Section 20, the Board shall not issue a certificate of registration only in the following instances: (1) to any candidate who has been convicted by a court of competent jurisdiction of any criminal offense involving moral turpitude; (2) or has been found guilty of immoral or dishonorable conduct after the investigation by the Board; or (3) has been declared to be of unsound mind. They aver that none of these circumstances are present in their case.

S A N T O S ,

M A R A N O ,

D E

G U Z M A N

&

F R A N C I S C O

E R A

C O L L E G E O F L A W J D B L O C K - C

Petitioners reject respondents argument. Section 8 [30] of Rep. Act No. 2382 prescribes, among others, that a person who aspires to practice medicine in the Philippines, must have satisfactorily passed the corresponding Board Examination. Section 22, in turn, provides that the oath may only be administered to physicians who qualified in the examinations. The operative word here is satisfactorily, defined as sufficient to meet a condition or obligation or capable of dispelling doubt or ignorance. Gleaned from Board Resolution No. 26, the licensing authority apparently did not find that the respondents satisfactorily passed the licensure examinations. The Board instead sought to nullify the examination results obtained by the respondents. 2. DECS vs San Diego (GRN 89572, December 21, 1989) FACTS: Roberto Rey San Diego, the private respondent is a graduate of the University of the East with a degree of Bachelor of Science in Zoology. The petitioner claims that he took the NMAT three times and flunked it as many times. ISSUE: Petition whether the private respondent who has thrice failed the National Medical Admission Test(NMAT) is entitled to take it again as it is a requirement for admission to any Medical School in the Philippines. He invoked of his constitutional rights to academic freedom and quality education, squarely challenging the constitutionality of MECS Order No. 12, Series of 1972. HELD: The private respondent cannot take the NMAT again and pursue his medical profession because of the following grounds: For the pur po se of g a ug in g at lea st i nit i a l ly b y t he a dm i ssio n te st an d b y th e t hree -f l un k r ul e, a student shall not be allowed to take the NMAT again after three successive failures. The State ensures that medical profession is not permeated by incompetents to whom patients may unwarily hand over their lives and health. It is not enough to simply invoke the right to quality education as a guarantee of the Constitution, while one has the right to aspire to be a doctor, he does not have the constitutional right to be a doctor; one must show that he is entitled to it because of his preparation and promise. T he con fl i ct th at t he ch al le n ge d r ule v i ol ate s t he e q ua l pr ote ct ion cla use i s n ot we l l-t a ken . Conformable to Article III, Section 1 of the Constitution, a law does not have to operate with equal force on all person or things II. MEDICAL ACT OF 1959, CODE OF ETHICS Objectives. This Act provides for and shall govern (a) the standardization and regulation of medical education; (b) the examination for registration of physicians; and (c) the supervision, control and regulation of the practice of medicine in the Philippines. For the purpose of implementing the provisions of this Act, there are created the following agencies: (1) the Board of Medical Education under the Department of Education, and (2) the Board of Medical Examiners (Board of Medicine) under the Commissioner of Civil Service NOW Professional Regulation Commission (PRC).

Page 1

LEGAL MEDICINE REVIEWER

N E W

The Board of Medical Education Its Functions The Board of Medical Education shall be composed of the 1. Secretary of Education or his duly authorized representative, as chairman; 2. the Secretary of Health or his duly authorized representative; 3. the Director of the Bureau of Private Schools or his duly authorized representative; 4. the chairman of the Board of Medical Examiners or his duly authorized representatives; 5. a representative of the Philippine Medical Association; 6. the Dean of the College of Medicine, University of the Philippines; 7. a representative of the Council of Deans of Philippine Medical Schools; and 8. a Representative of the Association of Philippine Medical Colleges, as members. The officials acting as chairman and members of the Board of Medical Education shall hold office during their incumbency in their respective positions. Functions: (Section 5) The functions of the Board of Medical Education shall be: 1. To determine and prescribe minimum requirements for admission into a recognized college of medicine; 2. To determine and prescribe requirements for minimum physical facilities of colleges of medicine, to wit: buildings, including hospitals, equipment and supplies, apparatus, instruments, appliances, laboratories, bed capacity for instruction purposes, operating and delivery rooms, facilities for out-patient services, and others, used for didactic and practical instructions in accordance with modern trends; 3. To determine and prescribe the minimum number and the minimum qualifications of teaching personnel, including studentteacher ratio and curriculum; 4. To determine and prescribe the number of students who should be allowed to take up the preparatory course taking into account the capacity of the different recognized colleges of medicine. 5. To select, determine and approve hospitals or some departments of the hospitals for training which comply with the minimum specific physical facilities as provided in subparagraph (b) hereof: and 6. To promulgate and prescribe and enforce necessary rules and regulations for the proper implementation of the foregoing functions.

General practice of Medicine (Art 3 Section 8) No person shall engage in the practice of medicine in the Philippines unless: S A N T O S ,

M A R A N O ,

D E

G U Z M A N

&

F R A N C I S C O

C O L L E G E O F L A W J D B L O C K - C

(1) he is at least twenty-one years of age, (2) has satisfactorily passed the corresponding Board of Examination and (3) is a holder of a valid Certificate of Registration duly issued to him by the Board of Medical Examiners. Acts Constituting Practice of Medicine (Section 10) A person shall be considered as engaged in the practice of medicine (1) who shall, for compensation, fee, salary or reward in any form, paid to him directly or through another, or even without the same, physical examine any person, and diagnose, treat, operate or prescribe any remedy for any human disease, injury, deformity, physical, mental or physical condition or any ailment, real or imaginary, regardless of the nature of the remedy or treatment administered, prescribed or recommended; or (2) who shall, by means of signs, cards, advertisements, written or printed matter, or through the radio, television or any other means of communication, either offer or undertake by any means or method to diagnose, treat, operate or prescribe any remedy for any human disease, injury, deformity, physical, mental or physical condition; or (3) who shall use the title M.D. after his name. Exemptions (Section 11): The preceding section shall not be construed to affect 1.

2. 3.

4.

5. Admission requirements (Section 7) The medical college may admit any student who has not been convicted by any court of competent jurisdiction of any offense involving moral turpitude and who presents 1. a record showing completion of a bachelor's degree in science or arts; 2. a certificate of eligibility for entrance to a medical school from the Board of Medical Education; 3. a certificate of good moral character issued by two former professors in the college of liberal arts; and 4. birth certificate. Nothing in this Act shall be construed to inhibit any college of medicine from establishing, in addition to the preceding, other entrance requirements that may be deemed admissible.

E R A

6.

7.

any medical student duly enrolled in an approved medical college or school under training, serving without any professional fee in any government or private hospital, provided that he renders such service under the direct supervision and control of a registered physician; any legally registered dentist engaged exclusively in the practice of dentistry; any duly registered masseur or physiotherapist, provided that he applies massage or other physical means upon written order or prescription of a duly registered physician, or provided that such application of massage or physical means shall be limited to physical or muscular development; any duly registered optometrist who mechanically fits or sells lenses, artificial eyes, limbs or other similar appliances or who is engaged in the mechanical examination of eyes for the purpose of constructing or adjusting eye glasses, spectacles and lenses; any person who renders any service gratuitously in cases of emergency, or in places where the services of a duly registered physician, nurse or midwife are not available; any person who administers or recommends any household remedy as per classification of existing Pharmacy Laws; and any psychologist or mental hygienist in the performance of his duties, provided such performance is done in conjunction with a duly registered physician.

Limited practice without any certificate of registration (Section 12) 1.

Physicians and surgeons from other countries called in consultation only and exclusively in specific and definite cases, or those attached to international bodies or organization assigned to perform certain definite work in the Philippines provided they shall limit their practice to the specific work assigned to them and provided further

Page 2

LEGAL MEDICINE REVIEWER

N E W

they shall secure a previous authorization from the Board of Medical Examiners. 2.

Commissioned medical officers of the United States armed forces stationed in the Philippines while rendering service as such only for the members of the said armed forces and within the limit of their own respective territorial jurisdiction.

3.

Foreign physicians employed as exchange professors in special branches of medicine or surgery whose service may in the discretion of the Board of Medical Education, be necessary.

4.

Medical students who have completed the first four years of medical course, graduates of medicine and registered nurses who may be given limited and special authorization by the Secretary of Health to render medical services during epidemics or national emergencies whenever the services of duly registered physicians are not available. Such authorization shall automatically cease when the epidemic or national emergency is declared terminated by the Secretary of Health.

Functions of the Board of Medical Examiners (Board of Medicine) The Board of Medical Examiners, with the approval of the Professional Service Commission, shall promulgate such rules and regulations as may be necessary for the proper conduct of the examinations, correction of examination papers, and registration of physicians Section 22. Administrative investigations. In addition to the functions provided for in the preceding sections, the Board of Medical Examiners shall perform the following duties: (1) to administer oath to physicians who qualified in the examination; (2) to study the conditions affecting the practice of medicine in all parts of the Philippines; (3) to exercise the powers conferred upon it by this article with the view of maintaining the ethical and professional standards of the medical profession; (4) to subpoena or subpoena duces tecum witnesses for all purposes required in the discharge of its duties; and (5) to promulgate, with the approval of the Commissioner of Civil Service, such rules and regulations as it may deem necessary for the performance of its duties in harmony with the provisions of this Act and necessary for the proper practice of medicine in the Philippines.

DUE PROCESS: Section 23. Procedure and rules. Within five days after the filling of written charges under oath, the respondent physician shall be furnished a copy thereof, without requiring him or her to answer the same, and the Board shall conduct the investigation within five days after the receipt of such copy by the respondent. The investigation shall be completed as soon as practicable. SECTION 24. GROUNDS FOR REPRIMAND, SUSPENSION OR REVOCATION OF REGISTRATION CERTIFICATE. (1) Conviction by a court of competent jurisdiction of any criminal offense involving moral turpitude; (2) Immoral or dishonorable conduct; S A N T O S ,

M A R A N O ,

D E

G U Z M A N

&

F R A N C I S C O

E R A

C O L L E G E O F L A W J D B L O C K - C

(3) Insanity; (4) Fraud in the acquisition of the certificate of registration; (5) Gross negligence, ignorance or incompetence in the practice of his or her profession resulting in an injury to or death of the patient; (6) Addiction to alcoholic beverages or to any habit forming drug rendering him or her incompetent to practice his or her profession, or to any form of gambling; (7) False or extravagant or unethical advertisements wherein other things than his name, profession, limitation of practice, clinic hours, office and home address, are mentioned. (8) Performance of or aiding in any criminal abortion; (9) Knowingly issuing any false medical certificate; (10) Issuing any statement or spreading any news or rumor which is derogatory to the character and reputation of another physician without justifiable motive; (11) Aiding or acting as a dummy of an unqualified or unregistered person to practice medicine; (12) Violation of any provision of the Code of Ethics as approved by the Philippine Medical Association. Refusal of a physician to attend a patient in danger of death is not a sufficient ground for revocation or suspension of his registration certificate if there is a risk to the physician's life. Section 26. Appeal from judgment. The decision of the Board of Medical Examiners (Board of Medicine) shall automatically become final thirty days after the date of its promulgation unless the respondent, during the same period, has appealed to the Professional Regulation Commission and later to the Court of Appeals. If the final decision is not satisfactory, the respondent may ask for a review of the case, or may file in court a petition for certiorari. Section 27. Reinstatement. After two years, the Board may order the reinstatement of any physicians whose certificate of registration has been revoked, if the respondent has acted in an exemplary manner in the community wherein he resides and has not committed any illegal, immoral or dishonorable act. III. LIABILITIES OF PHYSICIANS Kinds of Liabilities of Physicians: 1. Administrative liabilities 2. Civil liabilities 3. Criminal liabilities i. Administrative Liability A practice of medicine is a privilege and not a right; hence it could be taken away from the physician. In administrative liabilities, a physician’s profession is temporarily withdrawn from him to protect future patients. Penalty: Reprimand, Suspension or revocation of license Quantum of Evidence: Substantial Evidence Jurisdiction: Board of Medicine, Professional Regulatory Commission (Quasijudicial body); Philippine Medical Association Example: Non-compliance of National and Local laws which include Sanitary Code, Fire Code etc ii. Criminal Liability

Page 3

LEGAL MEDICINE REVIEWER

N E W

-For Acts or Omissions constituting a crime. Acts or omissions constituting a crime can be done with deceit (deliberate intent) and fault (negligence, imprudence, lack of skill/foresight).

o

Jurisdiction: Regular Courts iii. Civil Liability Civil liabilities make a physician liable to compensate the patient for the injury he suffered on account of his wrongful act or breach of contract. It may include moral or punitive damages. Penalty: Damages (NCC Arts 19-21 or Article 2176 Torts) Quantum of Evidence: Preponderance of Evidence Jurisdiction: Regular Courts IV. HUMAN BODY V. MEDICAL NEGLIGENCE CASES LEGAL MEDICINE AND THE LEGAL SYSTEM Courts routinely call upon physicians to give expert testimony in a trial, especially concerning the findings of an autopsy and the results of laboratory tests. As an expert witness he is allowed to express an opinion about the validity of the evidence in a case and may quote the statements of other experts in support of an opinion. Ordinary testimony is restricted to statements concerning what the witness actually saw or heard. The evidence to be presented by the legal medicine expert must signify a relation between the facts called the “ Factum Probandum” or proposition to be established and the “ factum Probans” which is the material evidencing the proposition. The Physician must present RELEVANT, MATERIAL AND COMPETENT EVIDENCE. 

If physician is an employee, the hospital may be held liable.  Physicians are not employees but are considered as individual contractors.  Key elements (Employer-employee relationship): 1. Hiring 2. Firing 3. Wages 4. Control  How to make a hospital under the doctrine of apparent authority liable General Rule: A hospital is not liable for the negligence of an independent contractor-physician. XPT: When physician is the "ostensible" agent of the hospital (doctrine of apparent authority) Requisites for the doctrine to apply: (1) the hospital, or its agent, acted in a manner that would lead a reasonable person to conclude that the individual who was alleged to be negligent was an employee or agent of the hospital;

M A R A N O ,

D E

C O L L E G E O F L A W J D B L O C K - C

(2) where the acts of the agent create the appearance of authority, the plaintiff must also prove that the hospital had knowledge of and acquiesced in them; and (3) the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with ordinary care and prudence.

Penalty: Imprisonment, fines (from Special Laws/ RPC) Quantum of Evidence: Proof beyond reasonable doubt

S A N T O S ,

E R A

G U Z M A N

&

F R A N C I S C O

LEGAL BASIS:  Law on Agency  Negligent Act of an agent, principal may be held liable.  Acting as an agent of the hospital 1. Forms 2. Waiver 3. Prescription pad 4. List of physicians 5. Corporate Negligence: How to make physician liable o Captain of the Ship Doctrine  Still applicable in the Philippines though western countries are not applying the same.  Mistakes not automatically negligence  Negligence is not sufficient; it must be gross negligence.  Standard of care: failure to follow it must be established  Pre-operative procedure  Expert witness: to establish failure to follow standard of care o Same expertise as the accused o Preferably from the same locality 

EXCEPTION: res ipsa loquitur The injury of the patient is sufficient Common sense will tell you that there was negligence

o

Four (4) elements: (1) the accident was of a kind which does not ordinarily occur unless someone is negligent; (2) the instrumentality or agency which caused the injury was under the exclusive control of the person in charge; and (3) the injury suffered must not have been due to any voluntary action or contribution of the person injured. (4) Matter of convenience on the part of the injured party

MEDICAL NEGLIGENCE CASES 3. Dr. Cantre vs. Go (G.R. No. 160889, April 27, 2007) FACTS: Hours after giving birth to her fourth child. Nora experienced hypoglemic shock. The attending physician and her team performed the necessary steps to stop the bleeding. He used a droplight to warm Nora and her baby. After the operation, Nora’s husband noticed a gaping wound on Nora’s left arm, about four (4) inches long. He asked the physician what caused the wound and he replied that it was due to the blood pressure cuff. The spouses went to the NBI for physical examination and found out that it was a burn caused by the droplight. A droplight can cause burn on the skin even just for ten (10) minutes. Thye filed a complaint for damages against the doctor and the hospital. The doctor said it was the nurse’s fault. The nurse forgot to remove the droplight. Page 4

LEGAL MEDICINE REVIEWER

N E W

ISSUE: Is the petitioner liable for the injury sustained by Nora Go? HELD: YES. Res ipsa loquitur x Medical negligence cases In medical negligence cases, the doctrine of res ipsa loquitur allows the mere existence of an injury to justify a presumption of negligence on the part of the person who controls the instrument causing the injury, provided that the following requisites concur: Accident is of a kind which ordinarily does not occur absent someone's negligence The wound not an ordinary occurrence in the act of delivering a baby; could not have happened unless negligence set in somewhere caused by an instrumentality within defendant's exclusive control It doesn't matter WON the injury was caused by the droplight or by the blood pressure cuff, since both are within the exclusive control of the physician in charge [Dr. Cantre] under the captain of the ship doctrine [surgeon in charge of an operation is held liable for his assistants' negligence during the time when they are under the surgeon's control]. The doctrine of [r]es ipsa loquitur as a rule of evidence is peculiar to the law of negligence which recognizes that prima facie negligence may be established without direct proof and furnishes a substitute for specific proof of negligence. In the instant case, all the requisites for recourse to the doctrine are present. First, the entire proceedings of the cesarean section were under the exclusive control of Dr. Batiquin. In this light, the private respondents were bereft of direct evidence as to the actual culprit or the exact cause of the foreign object finding its way into private respondent Villegas' body, which, needless to say, does not occur unless through the intervention of negligence. Second, since aside from the cesarean section, private respondent Villegas underwent no other operation which could have caused the offending piece of rubber to appear in her uterus, it stands to reason that such could only have been a by-product of the cesarean section performed by Dr. Batiquin. The petitioners, in this regard, failed to overcome the presumption of negligence arising from resort to the doctrine ofres ipsa loquitur. Dr. Batiquin is therefore liable for negligently leaving behind a piece of rubber in private respondent Villegas' abdomen and for all the adverse effects thereof.. Still, her good intentions characteristics do not justify negligence. 4. Batiquin vs Court of Appeals (GRN 118231, July 5, 1996) FACTS: On Sept 1988, Petitioner Dr. Batiquin performed a simple caesarean section on Respondent Mrs. Villegas when the latter gave birth. Soon after leaving the hospital, respondent began to suffer abdominal pains and complained of being feverish. The abdominal pains and fever kept on recurring and this prompted respondent to consult with another doctor, Dr. Kho. When Dr. Kho opened the abdomen of respondent to check her out respondent’s infection, she discovered that a piece of rubber material, which looked like a piece of rubber glove and was deemed a foreign body, was the cause of the respondent’s infection. Respondent then sued petitioner for damages. RTC held in favor of petitioner. CA reversed, ruling for the respondent. ISSUES: Whether petitioner is liable to respondent. HELD: YES, UNDER THE RULE OF RES IPSA LOQUITUR, DR. BATIQUIN IS LIABLE. Res ipsa loquitur. The thing speaks for itself. Rebuttable presumption or inference that defendant was negligent, which arises upon proof that the instrumentality causing injury was in defendant's exclusive control, and that the accident was one which S A N T O S ,

M A R A N O ,

D E

G U Z M A N

&

F R A N C I S C O

E R A

C O L L E G E O F L A W J D B L O C K - C

ordinary does not happen in absence of negligence. Res ipsa loquitur is a rule of evidence whereby negligence of the alleged wrongdoer may be inferred from the mere fact that the accident happened provided the character of the accident and circumstances attending it lead reasonably to belief that in the absence of negligence it would not have occurred and that thing which caused injury is shown to have been under the management and control of the alleged wrongdoer. Under this doctrine the happening of an injury permits an inference of negligence where plaintiff produces substantial evidence that the injury was caused by an agency or instrumentality under the exclusive control and management of defendant, and that the occurrence was such that in the ordinary course of things would not happen if reasonable care had been used. The doctrine of res ipsa loquitur as a rule of evidence is peculiar to the law of negligence which recognizes that prima facie negligence may be established without direct proof and furnishes a substitute for specific proof of negligence. The doctrine is not a rule of substantive law, but merely a mode of proof or a mere procedural convenience. The rule, when applicable to the facts and circumstances of a particular case, is not intended to and does not dispense with the requirement of proof of culpable negligence on the party charged. It merely determines and regulates what shall be prima facie evidence thereof and facilitates the burden of plaintiff of proving a breach of the duty of due care. The doctrine can be invoked when and only when, under the circumstances involved, direct evidence is absent a n d n ot re a di l y a v a i la b le. In the instant case, all the requisites for recourse to the doctrine are present. First, the entire proceedings of the caesarean section were under the exclusive control of Dr. Batiquin. In this light, the private respondents were bereft of direct evidence as to the actual culprit or the exact cause of the foreign object finding its way into private respondent Villegas's body, which, needless to say, does not occur unless through the intersection of negligence. Second, since aside from the caesarean section, private respondent Villegas underwent no other operation which could have caused the offending piece of rubber to appear in her uterus, it stands to reason that such could only have been a by-product of the caesarean section performed by Dr. Batiquin. The petitioners, in this regard, failed to overcome the presumption of negligence arising from resort to the doctrine of res ipsa loquitur. Dr. Batiquin is therefore liable for negligently leaving behind a piece of rubber in private respondent Villegas's abdomen and for all the adverse effects thereof. 5. Fe Lasam vs. Ramolete (G.R. No. 159132, December 18, 2008) FACTS: On July 28, 1994, respondent, three months pregnant Editha Ramolete was brought to the Lorma Medical Center (LMC) in San Fernando, La Union due to vaginal bleeding. Upon advice of petitioner relayed Via telephone, Editha was admitted to the LMC on the same day. A pelvic sonogram was then conducted on Editha revealing the fetus’ weak cardiac pulsation. The following day, Editha’s repeat pelvic sonogram showed that aside from the fetus’ weak cardiac pulsation, no fetal movement was also appreciated. Due to persistent and profuse vaginal bleeding, petitioner advised Editha to undergo a Dilatation and Curettage Procedure (D&C) or "raspa." The procedure was performed by the petitioner and Editha was discharged the next day. On September 16, 1994, Editha was once again brought at the LMC, as she was suffering from vomiting and severe abdominal pains. She was found to have a massive intra-abdominal hemorrhage and a ruptured uterus. Thus, Editha had to undergo a procedure for hysterectomy and as a result, she has no more chance to bear a child. Page 5

LEGAL MEDICINE REVIEWER

N E W

Respondents: Petitioner’s failure to check up, visit or administer medication on Editha during her first day of confinement at the LMC; Petitioner recommended that a D&C procedure be performed on Editha without conducting any internal examination prior to the procedure; Petitioner immediately suggested a D&C procedure instead of closely monitoring the state of pregnancy of Editha. Petitioner: it was Editha’s gross negligence and/or omission in insisting to be discharged against doctor’s advice and her unjustified failure to return for check-up as directed by petitioner that contributed to her life-threatening condition on; that Editha’s hysterectomy was brought about by her very abnormal pregnancy known as placenta increta, which was an extremely rare and very unusual case of abdominal placental implantation; that whether or not a D&C procedure was done by her or any other doctor, there would be no difference at all because at any stage of gestation before term, the uterus would rupture just the same. HELD: Medical malpractice is a particular form of negligence which consists in the failure of a physician or surgeon to apply to his practice of medicine that degree of care and skill which is ordinarily employed by the profession generally, under similar conditions, and in like surrounding circumstances. There are four elements involved in medical negligence cases: duty, breach, injury and proximate causation. In the present case, respondents did not present any expert testimony to support their claim that petitioner failed to do something which a reasonably prudent physician or surgeon would have done. Petitioner, on the other hand, presented the testimony of Dr. Augusto M. Manalo, who was clearly an expert on the subject. He testified that the rupture occurred minutes prior to the hysterectomy or right upon admission on September 15, 1994 which is about 1½ months after the patient was discharged, after the D&C was conducted. It is evident that the D&C procedure was not the proximate cause of the rupture of Editha’s uterus. The defenses in an action for damages, provided for under Article 2179 of the Civil Code are: When the plaintiff’s own negligence was the immediate and proximate cause of his injury he cannot recover damages. But if his negligence was only contributory, the immediate and proximate cause of the injury being the defendant’s lack of due care, the plaintiff may recover damages, but the courts shall mitigate the damages to be awarded. Proximate cause has been defined as that which, in natural and continuous sequence, unbroken by any efficient intervening cause, produces injury, and without which the result would not have occurred. An injury or damage is proximately caused by an act or a failure to act, whenever it appears from the evidence in the case that the act or omission played a substantial part in bringing about or actually causing the injury or damage; and that the injury or damage was either a direct result or a reasonably probable consequence of the act or omission. The Court notes the findings of the Board of Medicine: When complainant was discharged on July 31,1994, herein respondent advised her to return on August 4, 1994 or four (4) days after the D&C. This advice was clear in complainant’s Discharge Sheet. However, Complainant failed to do so. This being the case, the chain of continuity as required in order that the doctrine of proximate cause can be validly invoked was interrupted. Had she S A N T O S ,

M A R A N O ,

D E

G U Z M A N

&

F R A N C I S C O

E R A

C O L L E G E O F L A W J D B L O C K - C

returned, the respondent could have examined her thoroughly. Contributory negligence is the act or omission amounting to want of ordinary care on the part of the person injured, which, concurring with the defendant’s negligence is the proximate cause of the injury. Difficulty seems to be apprehended in deciding which acts of the injured party shall be considered immediate causes of the accident. Where the immediate cause of an accident resulting in an injury is the plaintiff’s own act, which contributed to the principal occurrence as one of its determining factors, he cannot recover damages for the injury. 6. Rogelio Nogales vs. Capitol Medical Center (G.R. No. 142625, December 19, 2006) FACTS: Dr. Estrada applied low forceps to extract Corazon's baby. In the process, a cervical tissue was allegedly torn. The baby came out in an apnic, cyanotic, weak and injured condition. The bab survived, but the mother died of profuse vaginal bleeding. The husband sued CMC and the doctors. ISSUES: 1) Whether an employee-employer relationship existedbetween CMC and Dr. Estrada 2) whether CMC is vicariously liable for the negligence of Dr. Estrada HELD: In Ramos vs. CA, weheld: In other words, private hospitals, hire, fire and exercise real control over their attending and visiting "consultant" staff. While "consultants" are not, technically employees, the control exercised, the hiring, and the right to terminate consultants all fulfill the important hallmarks of an employer-employee relationship, with the exception of the payment of wages. In assessing whether such a relationship in fact exists, the control test is determining. Accordingly, on the basis of the foregoing, we rule that for the purpose of allocating responsibility in medical negligence cases, an employer-employee relationship in effect exists between hospitals and their attending and visiting physicians. Dr. Estrada is an independent contractor. Applying the control test, SC did not find evidence pointing to CMC's exercise of control over Dr. Estrada's treatment and management of Corazon's condition. The patient was under the exclusive prenatal care of Dr. Estrada. CMC merely allowed Dr. Estrada to use its facilities when Corazon was about to give birth, which CMC considered an emergency. But while SC held that Dr. Estrada is not CMC’s employee, CMC is vicariously liable under the doctrine of apparent authority. General Rule: A hospital is not liable for the negligence of an independent contractor-physician. XPT: When physician is the "ostensible" agent of the hospital (doctrine of apparent authority) Requisites for the doctrine to apply: (1) the hospital, or its agent, acted in a manner that would lead a reasonable person to conclude that the individual who was alleged to be negligent was an employee or agent of the hospital; (2) where the acts of the agent create the appearance of authority, the plaintiff must also prove that the hospital had knowledge of and acquiesced in them; and (3) the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with ordinary care and prudence. Two Factors to consider: 1) An inquiry on whether the hospital acted in a manner which would lead a reasonable person to conclude that the individual who was alleged to be negligent was an employee or agent of the hospital. The hospital need not make express representations to the

Page 6

LEGAL MEDICINE REVIEWER

N E W

patient that the treating physician is an employee of the hospital; rather a representation may be general and implied. 2) An inquiry on whether the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with ordinary care and prudence. Application of these factors to this case: 1) CMC impliedly held out Estrada as a member of its medical staff. a) CMC granted staff privileges to Dr. Estrada. CMC extended its medical staff and facilities to Dr. Estrada. b) CMC made Rogelio sign consent forms printed on CMC letterhead. These forms did not indicate that he was an independent contractor-physician. No one from CMC informed the Spouses c) Dr. Estrada's referral of Corazon's profuse vaginal bleeding to Dr. Espinola, who was then the Head of the Obstetrics and Gynecology Department of CMC, gave the impression that Dr. Estrada as a member of CMC's medical staff was collaborating with other CMCemployed specialists in treating Corazon. 2) Rogelio testified that he and his wife specifically chose Dr. Estrada to handle Corazon's delivery not only because of their friend's recommendation, but more importantly because of Dr. Estrada's "connection with a reputable hospital, the CMC." In other words, Dr. Estrada's relationship with CMC played a significant role in the Spouses Nogales' decision in accepting Dr. Estrada's services 7. Professional Services vs. Agana (G.R. No. 126297, February 2, 2010) In this case, the Court, while affirming the existing doctrine that hospitals as a general rule are not civilly liable for the tortuous acts of their medical consultants in view of the absence of an employeremployee relationship between, nonetheless made the following pro hac vice doctrinal pronouncements on the liability of the respondent hospital based on the doctrines of “ostensible agency” and “corporate negligence”, thus: FACTS: Professional Services, Inc. (PSI) filed a second motion for reconsideration urging referral thereof to the Court en banc and seeking modification of the decision dated January 31, 2007 and resolution dated February 11, 2008 which affirmed its vicarious and direct liability for damages to respondents Enrique Agana and the heirs of Natividad Agana (Aganas). Manila Medical Services, Inc. (MMSI), Asian Hospital, Inc. (AHI), and Private Hospital Association of the Philippines (PHAP) all sought to intervene in these cases invoking the common ground that, unless modified, the assailed decision and resolution will jeopardize the financial viability of private hospitals and jack up the cost of health care. ISSUE: Whether or not Professional Services Inc. has been erred to be held liable for the Negligence of Dr. Miguel Ampil. HELD: YES, after gathering its thoughts on the issues, this Court holds that PSI is liable to the Aganas, not under the principle of respondeat superior for lack of evidence of an employment relationship with Dr. Ampil but under the principle of ostensible agency for the negligence of Dr. Ampil and, pro hac vice, under the principle of corporate negligence for its failure to perform its duties as a hospital. While in theory a hospital as a juridical entity cannot practice medicine, in reality it utilizes doctors, surgeons and medical practitioners in the conduct of its business of facilitating medical and surgical treatment.

S A N T O S ,

M A R A N O ,

D E

G U Z M A N

&

F R A N C I S C O

E R A

C O L L E G E O F L A W J D B L O C K - C

**Where an employment relationship exists, the hospital may be held vicariously liable under Article 2176 in relation to Article 2180 of the Civil Code or the principle of respondeat superior. Even when no employment relationship exists but it is shown that the hospital holds out to the patient that the doctor is its agent, the hospital may still be vicariously liable under Article 2176 in relation to Article 1431 and Article 1869 of the Civil Code or the principle of apparent authority. Moreover, regardless of its relationship with the doctor, the hospital may be held directly liable to the patient for its own negligence or failure to follow established standard of conduct to which it should conform as a corporation. **Under the "control test", an employment relationship exists between a physician and a hospital if the hospital controls both the means and the details of the process by which the physician is to accomplish his task. As priorly stated, private respondents maintained specific work-schedules, as determined by petitioner through its medical director, which consisted of 24-hour shifts totaling forty-eight hours each week and which were strictly to be observed under pain of administrative sanctions. **That petitioner exercised control over respondents gains light from the undisputed fact that in the emergency room, the operating room, or any department or ward for that matter, respondents' work is monitored through its nursing supervisors, charge nurses and orderlies. Without the approval or consent of petitioner or its medical director, no operations can be undertaken in those areas. For control test to apply, it is not essential for the employer to actually supervise the performance of duties of the employee, it being enough that it has the right to wield the power. 8. Ramos vs. Court of Appeals (G.R. No. 124354 , April 11, 2002) FACTS: Erlinda Ramos, after seeking professional medical help, was advised to undergo an operation for the removal of a stone in her gall bladder (cholecystectomy). She was referred to Dr. Hosaka, a surgeon, who agreed to perform the operation on her. The operation was scheduled for June 17, 1985 at 9:00 in the morning at private respondent De Los Santos Medical Center (DLSMC). Since neither petitioner Erlinda nor her husband, petitioner Rogelio, knew of any anesthesiologist, Dr. Hosaka recommended to them the services of Dr. Gutierrez. Petitioner Erlinda was admitted to the DLSMC the day before the scheduled operation. By 7:30 in the morning of the following day, petitioner Erlinda was already being prepared for operation. Upon the request of petitioner Erlinda, her sister-in-law, Herminda Cruz, who was then Dean of the College of Nursing at the Capitol Medical Center, was allowed to accompany her inside the operating room. At around 9:30 in the morning, Dr. Hosaka had not yet arrived so Dr. Gutierrez tried to get in touch with him by phone. Thereafter, Dr. Gutierrez informed Cruz that the operation might be delayed due to the late arrival of Dr. Hosaka. In the meantime, the patient, petitioner Erlinda said to Cruz, "Mindy, inip na inip na ako, ikuha mo ako ng ibang Doctor." By 10:00 in the morning, when Dr. Hosaka was still not around, petitioner Rogelio already wanted to pull out his wife from the operating room. He met Dr. Garcia, who remarked that he was also tired of waiting for Dr. Hosaka. Dr. Hosaka finally arrived at the hospital at around 12:10 in the afternoon, or more than three (3) hours after the scheduled operation. Cruz, who was then still inside the operating room, heard about Dr. Hosaka’s arrival. While she held the hand of Erlinda, Cruz Page 7

LEGAL MEDICINE REVIEWER

N E W

E R A

C O L L E G E O F L A W J D B L O C K - C

saw Dr. Gutierrez trying to intubate the patient. Cruz heard Dr. Gutierrez utter: "ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan." Cruz noticed a bluish discoloration of Erlinda’s nailbeds on her left hand. She (Cruz) then heard Dr. Hosaka instruct someone to call Dr. Calderon, another anesthesiologist. When he arrived, Dr. Calderon attempted to intubate the patient. The nailbeds of the patient remained bluish, thus, she was placed in a trendelenburg position – a position where the head of the patient is placed in a position lower than her feet. At this point, Cruz went out of the operating room to express her concern to petitioner Rogelio that Erlinda’s operation was not going well.

3) After a careful consideration of the arguments raised by DLSMC, the Court finds that respondent hospital’s position on this issue is meritorious. There is no employer-employee relationship between DLSMC and Drs. Gutierrez and Hosaka which would hold DLSMC solidarily liable for the injury suffered by petitioner Erlinda under Article 2180 of the Civil Code. urther, no evidence was adduced to show that the injury suffered by petitioner Erlinda was due to a failure on the part of respondent DLSMC to provide for hospital facilities and staff necessary for her treatment. For these reasons, the Supreme Cord reverse the finding of liability on the part of DLSMC for the injury suffered by petitioner Erlinda.

Cruz quickly rushed back to the operating room and saw that the patient was still in trendelenburg position. At almost 3:00 in the afternoon, she saw Erlinda being wheeled to the Intensive Care Unit (ICU). The doctors explained to petitioner Rogelio that his wife had bronchospasm. Erlinda stayed in the ICU for a month. She was released from the hospital only four months later or on November 15, 1985. Since the ill-fated operation, Erlinda remained in comatose condition until she died on August 3, 1999.

9. Cereno vs. CA (G.R. No. 167366 September 26, 2012) FACTS: At 10:30 P.M., Raymond was brought inside the operating room. For During that time, the hospital surgeons, Drs. Zafe and Cereno, were busy operating on gunshot victim. Meanwhile, another emergency case, a woman who was giving birth to triplets and was brought to the operating room with the only anaesthesiologist, Dr Tatad.

Petitioners filed with the Regional Trial Court of Quezon City a civil case for damages against private respondents. After due trial, the court a quo rendered judgment in favor of petitioners. Essentially, the trial court found that private respondents were negligent in the performance of their duties to Erlinda. On appeal by private respondents, the Court of Appeals reversed the trial court’s decision and directed petitioners to pay their "unpaid medical bills" to private respondents. Petitioners filed with this Court a petition for review on certiorari. The private respondents were then required to submit their respective comments thereon. On December 29, 1999, this Court promulgated the decision which private respondents now seek to be reconsidered. ISSUES: 1. WHETHER OR NOT DR. ORLINO HOSAKA (SURGEON) IS LIABLE FOR NEGLIGENCE; 2. WHETHER OR NOT DR. PERFECTA GUTIERREZ (ANESTHESIOLOGIST) IS LIABLE FOR NEGLIGENCE; AND 3. WHETHER OR NOT THE HOSPITAL (DELOS SANTOS MEDICAL CENTER) IS LIABLE FOR ANY ACT OF NEGLIGENCE COMMITTED BY THEIR VISITING CONSULTANT SURGEON AND ANESTHESIOLOGIST. RULING: In the case at bar, the following issues were resolved as follows: 1) Dr. Hosaka's irresponsible conduct of arriving very late for the scheduled operation of petitioner Erlinda is violative, not only of his duty as a physician "to serve the interest of his patients with the greatest solicitude, giving them always his best talent and skill," 44 but also of Article 19 of the Civil Code which requires a person, in the performance of his duties, to act with justice and give everyone his due. 2) Dr. Gutierrez’ claim of lack of negligence on her part is belied by the records of the case. It has been sufficiently established that she failed to exercise the standards of care in the administration of anesthesia on a patient. Dr. Gutierrez omitted to perform a thorough preoperative evaluation on Erlinda. Further, there is no cogent reason for the Court to reverse its finding that it was the faulty intubation on Erlinda that caused her comatose condition. There is no question that Erlinda became comatose after Dr. Gutierrez performed a medical procedure on her. S A N T O S ,

M A R A N O ,

D E

G U Z M A N

&

F R A N C I S C O

After some time, Drs. Zafe and Cereno, proceeded to examine Raymond and they found that the latters blood pressure was normal and "nothing in him was significant." There being no other available anesthesiologist to assist them, Drs. Zafe and Cereno decided to defer the operation on Raymond. At 11:15 P.M, Drs. Cereno and Zafe started their operation on Raymond at around 12:15 A.M., upon opening of Raymonds thoracic cavity, they found that 3,200 cc of blood was stocked therein. Dr. Cereno did not immediately transfuse the blood since the bleeders had to be controlled first. Blood was finally transfused on Raymond at 1:40 A.M. However, during the operation, Raymond died due to massive loss of blood. Parents of Raymond filed a case against the doctors. The doctors were found negligently liable. Hence this appeal. ISSUE: Whether or not Drs. Zafe and Cereno are guilty of gross negligence in the performance of their duties. HELD: NO. The type of lawsuit which has been called medical malpractice or, more appropriately, medical negligence, is that type of claim which a victim has available to him or her to redress a wrong committed by a medical professional which has caused bodily harm. In order to successfully pursue such a claim, a patient must prove that a health care provider, in most cases a physician, either failed to do something which a reasonably prudent health care provider would have done, or that he or she did something that a reasonably prudent provider would not have done; and that the failure or action caused injury to the patient. Given that Dr. Tatad was already engaged in another urgent operation and that Raymond was not showing any symptom of suffering from major blood loss requiring an immediate operation, We find it reasonable that petitioners decided to wait for Dr. Tatad to finish her surgery and not to call the standby anesthesiologist anymore. There is, after all, no evidence that shows that a prudent surgeon faced with similar circumstances would decide otherwise. In medical negligence cases, it is settled that the complainant has the burden of establishing breach of duty on the part of the doctors or surgeons. It must be proven that such breach of duty has a causal connection to the resulting death of the patient.

Page 8

LEGAL MEDICINE REVIEWER

N E W

Upon opening of his thoracic cavity, it was discovered that there was gross bleeding inside the body. Thus, the need for petitioners to control first what was causing the bleeding. 10. Jarcia vs. People (G.R. No. 187926 February 15, 2012) FACTS: Roy Alfonso Santiago Jr after being hit by a taxicab was brought by her mother to the Manila Doctors Hospital for an emergency treatment. Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr. Marilou Bastan (Dr. Bastan) junior (general) residents of the said hospital conducted an X-ray of the victim’s ankle and it was alleged that the X-ray result showed no fracture (as read by Dr. Jarcia); that Dr. Bastan entered the emergency room(ER) and, after conducting her own examination of the victim, informed Mrs. Santiago that since it was only the ankle that was hit, there was no need to examine the upper leg; that eleven (11) days later, Roy Jr. developed fever, swelling of the right leg and misalignment of the right foot; that Mrs. Santiago brought him back to the hospital; and that the Xray revealed a right mid-tibial fracture and a linear hairline fracture in the shaft of the bone. The NBI indorsed the matter to the Office of the City Prosecutor of Manila for preliminary investigation. Probable cause was found and a criminal case for reckless imprudence resulting to serious physical injuries, was filed against Dr. Jarcia, Dr. Bastan and Dr. Pamittan, before the RTC. They were found guilty beyond reasonable doubt of the crime of Simple Imprudence Resulting to Serious Physical Injuries. That the negligence exhibited by the two doctors does not approximate negligence of a reckless nature but merely amounts to simple imprudence. Simple imprudence consists in the lack of precaution displayed in those cases in which the damage impending to be caused is not the immediate nor the danger clearly manifest. The elements of simple imprudence are as follows. 1. that there is lack of precaution on the part of the offender; and 2. that the damage impending to be caused is not immediate of the danger is not clearly manifest. Dissatisfied, the petitioners appealed to the CA. After trial and applying the doctrine of res ipsa loquitor the RTC found petitioners to be guilty of simple negligence. The decision was affirmed in toto by the CA. ISSUES: (1) Whether or not res ipsa loquitor is applicable in this case. (2) Whether or not the petitioner physicians are criminally negligent RULING: As to the first issue: The doctrine of res ipsa loquitur does not apply since the circumstances that caused patient Roy Jr.’s injury and the series of tests that were supposed to be undergone by him to determine the extent of the injury suffered were not under the exclusive control of Drs. Jarcia and Bastan. It was established that they are mere residents of the Manila Doctors Hospital at that time who attended to the victim at the emergency room. While it may be true that the circumstances pointed out by the courts below seem doubtless to constitute reckless imprudence on the part of the petitioners, this conclusion is still best achieved, not through the scholarly assumptions of a layman like the patient’s mother, but by the unquestionable knowledge of expert witness/es. As to whether the petitioners have exercised the requisite degree of skill and care in treating patient Roy, Jr. is generally a matter of expert opinion. As to the second issue: Petitioners were negligent in their obligation. It was proven that a thorough examination was not performed on Roy Jr since as residents on duty at the emergency S A N T O S ,

M A R A N O ,

D E

G U Z M A N

&

F R A N C I S C O

E R A

C O L L E G E O F L A W J D B L O C K - C

room, Dr. Jarcia and Dr. Bastan were expected to know the medical protocol in treating leg fractures and in attending to victims of car accidents. Thus, simple negligence is resent if: (1) that there is lack of precaution on the part of the offender, and (2) that the damage impending to be caused is not immediate or the danger is not clearly manifest. In failing to perform an extensive medical examination to determine the extent of Roy Jr.’s injuries, Dr. Jarcia and Dr. Bastan were remiss of their duties as members of the medical profession. Assuming for the sake of argument that they did not have the capacity to make such thorough evaluation at that stage, they should have referred the patient to another doctor with sufficient training and experience instead of assuring him and his mother that everything was all right. Moreover, the contention of petitioners that they cannot be held liable since Roy is not their patient, since they are not the attending physicians but merely requested by the ER does not hold water. Physician-patient relationship exists when a patient engages the services of a physician, a physician-patient relationship is generated. And in accepting a case, the physician, for all intents and purposes, represents that he has the needed training and skill possessed by physicians and surgeons practicing in the same field; and that he will employ such training, care, and skill in the treatment of the patient. Thus, in treating his patient, a physician is under a duty to exercise that degree of care, skill and diligence which physicians in the same general neighborhood and in the same general line of practice ordinarily possess and exercise in like cases. Stated otherwise, the physician has the obligation to use at least the same level of care that any other reasonably competent physician would use to treat the condition under similar circumstances.” There is a physician-patient relationship in this case since the petitioner obliged themselves and examined the victim, and later assured the mother that everything was fine and that they could go home. Their assurance that everything is fine deprived the victim of seeking medical help. Petitioners were absolved in the criminal charge for the reason that a reasonable doubt existed but the are liable for damages. There is no direct evidence proving that it was their negligence that caused the suffering of Roy. 11. Rubi Li vs. Soliman (G.R. No. 165279 June 7 2011) An Application of the Common-Law Doctrine of Informed Consent in a Medical Malpractice (Medical Negligence) Case under Article 2176 of the Civil Code The ponencia enumerated the four essential elements that a plaintiff must prove in a medical malpractice action based on the doctrine of informed consent, paraphrased as follows: (1) the physician’s duty to disclose material risks; (2) the physician’s failure to disclose, or inadequate disclosure, of those risks; (3) the patient’s consent to the treatment she otherwise would not have consented to, which is a direct and proximate result of the physician’s failure to disclose; and (4) plaintiff’s injury as a consequence the proposed treatment. The gravamen in an informed consent case requires the plaintiff to point to significant undisclosed information relating to the treatment which would have altered her decision to undergo it.

Page 9

LEGAL MEDICINE REVIEWER

N E W

Applying the foregoing to this case, it was held that petitioner Dr. Rubi Li, an oncologist who performed chemotherapy on respondents’ daughter, who was sick with malignant bone cancer, adequately disclosed material risks inherent in the chemotherapy procedure performed with respondents’ consent. When petitioner informed the respondents beforehand of the side effects of chemotherapy, which includes lowered counts of white and red blood cells, decrease in blood platelets, possible kidney or heart damage and skin darkening, there is reasonable expectation on the part of the doctor that the parents of the child understood very well that the severity of these side effects will not be the same for all patients undergoing the procedure. As a physician, Dr. Li can reasonably expect the child’s parents to have considered the variables in the recommended treatment for their daughter afflicted with a life-threatening illness. On the other hand, it is difficult to give credence to the parents’ claim that petitioner Dr. Li told them of 95% chance of recovery for their daughter, as it was unlikely for doctors like petitioner who were dealing with grave conditions such as cancer to have falsely assured patients of chemotherapy’s success rate. Besides, informed consent laws in other countries generally require only a reasonable explanation of potential harms, so specific disclosures such as statistical data, may not be legally necessary. Quite incongruously, however, the ponencia went on to declare that in the absence of expert testimony on the standard of care in obtaining consent in chemotherapy treatment [since the witness for the respondents-parents was not an expert, not being an oncologist but a mere Medical Specialist of the Department of Health charged with receiving complaints against hospitals], the Court felt hesitant in defining the scope of mandatory disclosure in cases of malpractice based on lack of informed consent such as this case involving chemotherapy treatment. Petitioner Dr. Li was found NOT liable to pay damages to the suing parents. VI. MEDICO-LEGAL ASPECTS OF DEATH o

S A N T O S ,

Clinically dead; no BP, no respiration, no heartbeat, no heart rate o Temperature drop (3 hours) – cooling o Changes of muscle (3 stages)  Primary flaccidity (lupaypay)  Immediately || mainit pa  Rigor Mortis – rigidity  3-6 hours-12 hours – complete rigor mortis  Secondary Flaccidity (lupaypay ulit)  24-36 hours || malamig na o Putrefaction – 24-36 hours o Post mortem lividity – gravitating of the blood  (3 hours) while cooling || tells the position of the dead o Cadaveric spasm – local/certain  Portion of the muscle becomes rigid, not the entire body  Does not happen to all o Cannot give time of death but give clue if suicide o Stomach contents (3-4 hours) o Presence of flies/maggots (24hours)

M A R A N O ,

D E

G U Z M A N

&

F R A N C I S C O

E R A

C O L L E G E O F L A W J D B L O C K - C

VII. PHYSICAL INJURIES  Different kinds of injuries: o Contrusion – discoloration o Humatona – bukol (elevation)  Regions of the body:  Head  Hands  Ankle  Fingers  Toes  Thighs  Legs  Forearms  Face o Frontal o Zygomatic – cheeks o Mandible – mouth/jaw o Maxillam – ilalim ng ilong o Temporal – side o Parietal – lalamunan o Occipital – batok o Orbit – eyes  Body o Chest (L/R) o Abdomen  Right upper quadrant  Right lower  Left upper  Left lower  Epigastrro – gitna  Injuries o Laceration – blunt o Incision – sharp-edged instrument o Abrasion – gasgas o Stab – knife o Punctured – ice pick, screw driver (pointed objects) VIII. GUNSHOT WOUNDS o Gunshot    

Bullet Flame – (Singeing)- 6” Smoke- (Smudging)-12” Unburned powder – (asdfghjkl;’)-24”

IX. SEX CRIMES o Sex crimes  Defense wounds  Document laceration  Position – clock  Extent/degree o Incomplete o Complete o compound 12. People vs. Alverio (G.R. No. 194259, March 16, 2011) FACTS: Alverio was found guilty of the crime of rape. He appealed and questioned the decision on the ground that his guilt was not proved beyond reasonable doubt. Alverio raises three (3) grounds in support of his argument. First, he assails the trial court for giving credence to the sole testimony of the victim. He claims that the prosecution should have presented other witnesses to corroborate the testimony of the victim. Second, he contends that the medical certificate presented as evidence was not testified to by the signatory Page 10

LEGAL MEDICINE REVIEWER

N E W

himself and should therefore not be considered as corroborative evidence. Lastly, he claims that the trial court gravely erred in convicting him of the crime of rape for failure of the prosecution to prove his guilt beyond reasonable doubt. After a careful perusal of the records of this case, however, the Court is satisfied that the prosecution’s evidence sufficiently established Alverio’s guilt with moral certainty. In addition, Alverio submits that although the medical certificate was presented as evidence, its contents were never testified to by the signatory himself and, as such, cannot be considered as corroborative of the claim of the victim that she was raped. Such argument, however, cannot prosper. Medical evidence is dispensable and merely corroborative in proving the crime of rape. Besides, a medical certificate is not even necessary to prove the crime of rape. The gravamen of rape is carnal knowledge of a woman through force and intimidation. The elements needed to prove the crime of rape under paragraph 1(a) of Article 266-A of the Revised Penal Code are: (1) the offender is a man; (2) the offender had carnal knowledge of a woman; and (3) the act is accomplished by using force or intimidation. All these elements were sufficiently proved by the prosecution. The testimony of AAA overwhelmingly proves that Alverio raped her with the use of force and intimidation. Furthermore, Alverio’s defense of alibi cannot stand versus the positive identification of AAA. Nothing is more settled in criminal law jurisprudence than the rule that alibi and denial cannot prevail over the positive and categorical testimony and identification of the accused by the complainant. Accordingly, We find that the prosecution has discharged its burden of proving the guilt of Alverio beyond reasonable doubt. WHEREFORE, the appeal is DENIED. The CA Decision in CA-G.R. CR-H.C. No. 00020 finding accused-appellant Jimmy Alverio guilty of the crime charged is AFFIRMED 13. People vs. Domantay (G.R. No. 130612 May 11, 1999) FACTS: Domantay was found guilty with the crime of Rape with Homicide. Domantay appealed. Among his arguments was the fact thereis no sufficient evidence to hold him guilty of raping Jennifer Domantay. As the victim here was six years old, only carnal knowledge had to be proved to establish rape. Carnal knowledge is defined as the act of a man having sexual intercourse or sexual bodily connections with a woman. 52 For this purpose, it is enough if there was even the slightest contact of the male sex organ with the labia of the victim's genitalia. 53 However, there must be proof, by direct or indirect evidence, of such contact. Dr. Ronald Bandonill's report on the genital examination he had performed on the deceased reads: GENITAL EXAMINATION; showed a complete laceration of the right side of the hymen. The surrounding genital area shows signs of inflammation. xxx xxx xxx REMARKS: 1) Findings at the genital area indicate the probability of penetration of that area by a hard, rigid instrument. Hymenal laceration is not necessary to prove rape; neither does its presence prove its commission. As held in People v. Ulili, a medical certificate or the testimony of the physician is presented not to prove that the victim was raped but to show that the latter had lost her virginity. Consequently, standing alone, a physician's finding that the hymen of the alleged victim was lacerated does not prove rape. It is only when this is corroborated by other evidence proving carnal knowledge that rape may be deemed to have been established. S A N T O S ,

M A R A N O ,

D E

G U Z M A N

&

F R A N C I S C O

E R A

C O L L E G E O F L A W J D B L O C K - C

This conclusion is based on the medically accepted fact that a hymenal tear may be caused by objects other than the male sex organ or may arise from other causes. Dr. Bandonill himself admitted this. He testified that the right side of the victim's hymen had been completely lacerated while the surrounding genital area showed signs of inflammation. He opined that the laceration had been inflicted within 24 hours of the victim's death and that the inflammation was due to a trauma in that area. When asked by the private prosecutor whether the lacerations of the hymen could have been caused by the insertion of a male organ he said this was possible. But he also said when questioned by the defense that the lacerations could have been caused by something blunt other than the male organ. In contrast, in the case at bar, there is no circumstantial evidence from which to infer that accused-appellant sexually abused the victim. The only circumstance from which such inference might be made is that accused-appellant was seen with the victim walking toward the place where the girl's body was found. Maybe he raped the girl. Maybe he did not. Maybe he simply inserted a blunt object into her organ, thus causing the lacerations in the hymen. Otherwise, there is no circumstance from which it might reasonably be inferred that he abused her, e.g., that he was zipping up his pants, that there was spermatozoa in the girl's vaginal canal. Indeed, the very autopsy report of Dr. Bandonill militates against the finding of rape. In describing the stab wounds on the body of the victim, he testified: [A]fter examining the body I took note that were several stab wounds . . . these were all found at the back area sir . . . extending from the back shoulder down to the lower back area from the left to the right. Considering the relative physical positions of the accused and the victim in crimes of rape, the usual location of the external bodily injuries of the victim is on the face, neck, and anterior portion of her body. Although it is not unnatural to find contusions on the posterior side, these are usually caused by the downward pressure on the victim's body during the sexual assault. It is unquestionably different when, as in this case, all the stab wounds (except for a minor cut in the lower left leg) had their entry points at the back running from the upper left shoulder to the lower right buttocks. It is noteworthy that the deceased was fully clothed in blue shorts and white shirt when her body was immediately after it was found. Furthermore, there is a huge bloodstain in the back portion of her shorts. This must be because she wearing this piece of clothing when the stab wounds were inflicated or immediately thereafter, thus allowing the blood to seep into her shorts to such an extent. Even assuming that Jennifer had been raped, there is no sufficient proof that it was accused-appellant who had raped her. He did not confess to having raped the victim. From the foregoing, we cannot find that accused-appellant also committed rape. In the special complex crime of rape with homicide, both the rape and the homicide must be established beyond reasonable doubt. 14. Union Motor vs. NLRC (G.R. No. 159738 December 9, 2004) FACTS: Respondent Alejandro A. Etis was hired by petitioner as an automotive mechanic. On 22 September 1997, the respondent made a phone call to the company nurse and informed her that he had to take a sick leave as he had painful and unbearable tootache. Etis then consulted a dentist who scheduled him for a tooth extraction but the Page 11

LEGAL MEDICINE REVIEWER

N E W

same was rescheduled for several times due to inflammation. As a result, respondent was not able to report for work for 10 days. The petitioner considered respondent’s consecutive absences as abandonment of office under the Company Rules and terminated the services of the respondent. The respondent then filed a complaint for illegal dismissal before the arbitration branch of the NLRC against the petitioner. The Labor Arbiter rendered a Decision dismissing the complaint. The Labor Arbiter ruled that the respondent’s failure to report for work for ten (10) days without an approved leave of absence was equivalent to gross neglect of duty, and that his claim that he had been absent due to severe toothache leading to a tooth extraction was unsubstantiated. The Labor Arbiter stressed that "unnotarized medical certificates were self-serving and had no probative weight. Respondent then appealed to the NLRC. NLRC reversed the Labor Arbiter’s Decision. CA affirmed NLRC’s Decision. ISSUE: Do medical certificates need to be notarized in order to be admissible as evidence? RULING: NO. Nowhere in our jurisprudence requires that all medical certificates be notarized to be accepted as a valid evidence. Verification of documents is not necessary in order that the said documents could be considered as substantial evidence. The medical certificates were properly signed by the physicians; hence, they bear all the earmarks of regularity in their issuance and are entitled to full probative weight. Common sense dictates that an ordinary worker does not need to have these medical certificates to be notarized for proper presentation to his company to prove his ailment; hence, the Labor Arbiter a quo, in cognizance with the liberality and the appreciation on the rules on evidence, must not negate the acceptance of these medical certificates as valid pieces of evidence. 15. People vs. Colorado (G.R. No. 200792 November 14, 2012) FACTS: Neil Colorado was convicted by the RTC for raping his fullblood sister AAA who was then 12-year old when the crime was committed. Colorado appealed from the RTC’s decision to the CA, reiterating in his appeal the defenses of denial and alibi. The CA affirmed Colorado’s conviction. Colorado also questions the weight of Dr. Sanchez’s medico-legal certificate, arguing that AAA’s hymenal lacerations could have resulted from the sexual aggressions allegedly committed against her by DDD and their brother-in-law. ISSUE: Is a medical certificate necessary to prove the commission of rape? RULING: NO. As explained by the Court in People v. Balonzo, a medical certificate is not necessary to prove the commission of rape, as even a medical examination of the victim is not indispensable in a prosecution for rape. Expert testimony is merely corroborative in character and not essential to conviction. An accused can still be convicted of rape on the basis of the sole testimony of the private complainant. Furthermore, laceration of the hymen, even if considered the most telling and irrefutable physical evidence of sexual assault, is not always essential to establish the consummation of the crime of rape. In the context that is used in the RPC, "carnal knowledge," unlike its ordinary connotation of sexual intercourse, does not necessarily require that the vagina be penetrated or that the hymen be ruptured. Thus, even granting that AAA’s lacerations were not caused by Colorado, the latter could still be declared guilty of rape, after it was established that he succeeded in having carnal knowledge of the victim.

E R A

C O L L E G E O F L A W J D B L O C K - C

16. Atienza vs. Sioson (G.R. No. 177407 February 2011) FACTS: Private respondent Editha Sioson wen to Rizal Medical Center for check-up. The tests revealed that her left kidney is normal but the left is non-functioning and non-visualizing. Thus she underwent kidney operation. After the operation, Editha and her husband filed a complaint for gross negligence and/or incompetence committed by petitioner Atienza which consists of the removal of Editha’s fully functional right kidney, instead of the left nonfunctioning and non-visualizing kidney. To prove that her kidneys were both in their proper anatomical locations at the time she was operated, she offered as evidence photocopied medical documents. Petitioner filed his comments/objections to private respondents [Editha Siosons] formal offer of exhibits. He alleged that said exhibits are inadmissible because the same are mere photocopies, not properly identified and authenticated, and intended to establish matters which are hearsay. He added that the exhibits are incompetent to prove the purpose for which they are offered. BOM, however, admitted the said documents as evidence. ISSUE: Should the introduction of photocopied documents as evidence be allowed? RULING: YES. The introduction of secondary evidence, such as copies of the exhibits, is allowed. Witness Dr. Nancy Aquino testified that the Records Office of RMC no longer had the originals of the exhibits because [it] transferred from the previous building, x x x to the new building . Ultimately, since the originals cannot be produced, the BOM properly admitted Edithas formal offer of evidence and, thereafter, the BOM shall determine the probative value thereof when it decides the case. Furthermore, the fact sought to be established by the admission of Edithas exhibits, that her kidneys were both in their proper anatomical locations at the time of her operation, need not be proved as it is covered by mandatory judicial notice. 17. Custodio vs. Sandiganbayan (G.R. No. 96027-28, March 08, 2005) The report of the forensic group may not be considered as newly discovered evidence as petitioners failed to show that it was impossible for them to secure an independent forensic study of the physical evidence during the trial of the double murder case. It appears from their report that the forensic group used the same physical and testimonial evidence proferred during the trial, but made their own analysis and interpretation of said evidence. They cited the materials and methods that they used for their study, viz: MATERIALS AND METHODS MATERIALS: a. Court records of the case, especially photographs of: a) the stairway where the late Sen. Aquino and his escorts descended; b) the part of the tarmac where the lifeless bodies of the late Sen. Aquino and Galman fell; and c) the autopsy conducted by the NBI Medico-legal team headed by Dr. Mu[]oz; and the autopsy report of the late Sen. Benigno Aquino[,] Jr. signed by Dr. Mu[]oz and Dr. Solis; b. The gun and live ammunitions collected at the crime scene; c. A reference human skull photos and X-rays of the same to demonstrate wound location and bullet trajectory;

S A N T O S ,

M A R A N O ,

D E

G U Z M A N

&

F R A N C I S C O

Page 12

LEGAL MEDICINE REVIEWER

N E W

E R A

C O L L E G E O F L A W J D B L O C K - C

d. The reports of interviews and statements by the convicted military escorts, and other witnesses; e. Re-enactment of the killing of Aquino based on the military escorts[] version, by the military escorts themselves in the Bilibid Prison and by volunteers at the NAIA Tarmac; f. Various books and articles on forensic and the medico-legal field[;] g. Results of Forensic experiments conducted in relation to the case. METHODS: a. Review of the forensic exhibits presented in the court; b. Review of TSNs relevant to the forensic review; c. Study of and research on the guns, slugs and ammunitions allegedly involved in the crime; d. Interviews/re-enactment of the crime based on the militarys accounts, both in the Bilibid Prison where the convicts are confined and the MIA (now NAIA) stairway and tarmac; e. Conduct of ocular inspection and measurements on the actual crime scene (stairway and tarmac) at the old Manila International Airport (now NAIA); f. Retracing the slugs trajectory based on the autopsy reports and experts testimonies using an actual human skull; g. X-rays of the skull with the retraced trajectory based on the autopsy report and experts testimonies; h. Evaluation of the presented facts and opinions of local experts in relation to accepted forensic findings in international publications on forensic science, particularly on guns and [gunshot] wound injuries; i. Forensic experiments and simulations of events in relation to this case.[18]

S A N T O S ,

M A R A N O ,

D E

G U Z M A N

&

F R A N C I S C O

Page 13