Cruz v. CA

Dr. Ninevetch Cruz v. CA and Lydia Umali

1997 / Francisco / Petition for review on certiorari of a CA decision

Standard of conduct > Experts > Medical professionals

FACTS

Medical malpractice suit - type of claim which a victim has available to him/her to redress a wrong committed by a medical professional which has caused bodily harm; most often brought as a civil action for damages under NCC 2176 or a criminal case under RPC 365, with which a civil action for damages is impliedly instituted.

Lydia Umali was examined by Dr. Cruz who found a myoma [benign tumor] in her uterus, and scheduled her for a hysterectomy operation [removal of uterus] on 23 Mar 1991. Rowena Umali de Ocampo accompanied her mother to the hospital a day before the operation, and they spent the night there. Rowena noticed that the clinic was untidy, so she tried to persuade her mother not to proceed with the operation. The following day, Rowena asked Dr. Cruz if the operation could be postponed, but Lydia told her daughter that Dr. Cruz said that the operation must go on as scheduled. 

While Lydia's relatives were waiting, Dr. Ercillo (anesthesiologist) told them to buy tagamet ampules, and Rowena's sister went out to buy some. An hour later, Dr. Ercillo asked them to buy blood for Lydia, so they did. A few hours later, the operation was finished, but later, Dr. Cruz asked the family to buy additional blood, but there was no more type A blood available in the blood bank. A person arrived to donate blood which was later transfused to Lydia. Rowena noticed that her mother was gasping for breath--apparently, the oxygen supply had run out, so the family went out to buy oxygen. Later in the evening, she went into shock and her blood pressure dropped. She was then transferred to another hospital so she could be connected to a respirator and further examined. However, this transfer was without the consent of the relatives, who only found out about it when an ambulance came to take Lydia to the other hospital.

In the new hospital, she was re-operated upon by Dr. Cruz and Dr. Ercillo because blood was oozing out from her incision. They summoned Dr. Angeles, Ob-Gyne head of the new hospital, but when he arrived, Lydia was already in shock and possibly dead (BP: 0/0). Dr. Angeles told Drs. Cruz and Ercillo that there was nothing he could do. Lydia died while Dr. Cruz was closing her abdominal wall. Immediate cause of death is shock; disseminated intravascular coagulation (DIC) as antecedent cause.

Dr. Cruz and Dr. Ercillo were charged with reckless imprudence and negligence resulting in homicide of Lydia Umali. The Municipal Trial Court in Cities (MTCC) found Dr. Ercillo not guilty for insufficiency of evidence against her, but held Dr. Cruz responsible for Umali's death. RTC and CA affirmed MTCC.

Manifestation of negligence

• untidiness of clinic
• lack of provision of supplies
• the fact that the transfer was needed meant that there was something wrong in the way Dr. Cruz conducted operation
• no showing that pre-surgery procedure (clearance, blood typing/tests) was conducted

ISSUE AND HOLDING

WON the circumstances are sufficient to sustain a judgment of conviction against Dr. Cruz for reckless imprudence resulting in homicide. NO. DR. CRUZ IS ACQUITTED, BUT SHE IS STILL CIVILLY LIABLE (50K civil liability; 100k moral damages, 50k exemplary damages).

RATIO

Elements of reckless imprudence

1.     Offender does / fails to do an act

2.     Doing / failure to do act is voluntary

3.     Without malice

4.     Material damage results from reckless imprudence

5.     There is inexcusable lack of precaution, taking into consideration offender's employment, degree of intelligence, physical condition, other circumstances re: persons, time, place

Standard of care

Standard of care observed by other members of the profession in good standing under similar circumstances, bearing in mind the advanced state of the profession at the time of treatment or the present state of medical science

          When the physician's qualifications are admitted, 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 to his clients, unless the contrary is sufficiently established by expert testimony.

Expert testimony

Expert testimony is essential to establish standard of care of the profession, as well as that the physician's conduct in the treatment and care falls below such standard. It is also usually necessary to support the conclusion as to causation. There is an absence of any expert testimony re: standard of care in the case records. NBI doctors presented by the prosecution only testified as to the possible cause of death.

     While it may be true that the circumstances pointed out by the lower courts constitute reckless imprudence, this conclusion is still best arrived not through the educated surmises nor conjectures of laymen, including judges, but by the unquestionable knowledge of expert witnesses. The deference of courts to the expert opinion of qualified physicians stems from the realization that the latter possess unusual technical skills which laymen are incapable of intelligently evaluating.

Burden of establishing medical negligence on plaintiff

Plaintiff has the burden to establish this, and for a reasonable conclusion of negligence, there must be proof of breach of duty on the part of the surgeon, as well as a causal connection of such breach and the resulting death of patient. Negligence cannot create a right of action unless it is the proximate cause of the injury complained of (Chan Lugay v. St. Luke's Hospital, Inc.). In this case, no cogent proof exists that the circumstances caused Lydia's death, so the 4th element of reckless imprudence is missing.

     The testimonies of the doctors presented by the prosecution establish hemorrhage / hemorrhagic shock as the cause of death, which may be caused by several different factors. Autopsy did not reveal any untied cut blood vessel, nor was there a tie of a cut blood vessel that became loose. The findings of the doctors do not preclude the probability that a clotting defect (DIC) caused the hemorrhage and consequently, Lydia's death.

The Court has no recourse but to rely on the expert testimonies that substantiate Dr. Cruz' allegation that the cause of Lydia's death was DIC, which cannot be attributed to Dr. Cruz' fault or negligence. This probability was unrebutted during trial.