G.R. No. 163879, July 30, 2014
DR. ANTONIO P. CABUGAO, Petitioner, v. PEOPLE OF THE PHILIPPINES AND SPOUSES RODOLFO M. PALMA AND ROSARIO F. PALMA, Respondents.
[G.R. NO. 165805]
DR. CLENIO YNZON, Petitioner, v. PEOPLE OF THE PHILIPPINES AND SPOUSES RODOLFO M. PALMA AND ROSARIO F. PALMA, Respondents.
D E C I S I O N
That on or about June 17, 2000 in the City of Dagupan, Philippines, and within the jurisdiction of this Honorable Court, the above-named accused, DR. ANTONIO P. CABUGAO and DR. CLENIO YNZON, being then the attending physicians of one RODOLFO PALMA, JR., a minor 10 years old, confederating and acting jointly with one another, did, then and there, willfully, unlawfully and feloniously fail through negligence, carelessness and imprudence to perform immediate operation upon their patient, RODOLFO PALMA, JR. of acute appendicitis, when they, the said physicians, should have been done so considering that examinations conducted upon their patient Rodolfo Palma, Jr. seriously manifest to do so, causing by such negligence, carelessness, and imprudence the victim, RODOLFO PALMA JR., to die due to:chanRoblesvirtualLawlibraryArising from the same events, the Court resolved to consolidate these cases.4 The facts, as culled from the records, are as follows:cralawlawlibrary“CARDIORESPIRATORY ARREST, METABOLIC ENCEPHALOPATHY, SEPTICEMIA (ACUTE APPENDICITIS), CEREBRAL ANEURYSM RUPTURED (?)”
As per Certificate of Death issued by accused Dr. Antonio P. Cabugao, to the damage and prejudice of the legal heirs of said deceased RODOLFO PALMA, JR. and other consequential damages relative thereto.
CONTRARY to Article 365, 1st par. of the Revised Penal Code.
Dagupan City, Philippines, January 29, 2001.
Normal liver, bile ducts, gallbladder, pancreas, spleen, kidneys and urinary bladder.
There is no free peritoneal fluid.
There is localized tenderness in the paraumbilical region, more so in the supra and right paraumbilical areas.
There is a vague elongated hypoechoic focus in the right periumbilical region roughly about 47 x 18 mm surrounded by undistended gas-filled bowels. This is suggestive of an inflammatory process wherein appendiceal or periappendiceal pathology cannot be excluded. Clinical correlation is essential.”6
Immediate cause: CARDIORESPIRATORY ARREST
Antecedent cause: METABOLIC ENCEPHALOPATHY
Underlying cause: SEPTICEMIA (ACUTE APPENDICITIS)
Other significant conditions contributing to death:
CEREBRAL ANEURYSM RUPTURED (?)
It is unquestionable that JR was under the medical care of the accused from the time of his admission for confinement at the Nazareth General Hospital until his death. Upon his admission, the initial working diagnosis was to consider acute appendicitis. To assist the accused in the consideration of acute appendicitis, Dr. Cabugao requested for a complete blood count (CBC) and a diagnostic ultrasound on JR. The findings of the CBC and ultrasound showed that an inflammatory process or infection was going on inside the body of JR. Said inflammatory process was happening in the periumbilical region where the appendix could be located. The initial diagnosis of acute appendicitis appears to be a distinct possibility. x x x.
Dr. Ynzon ordered medications to treat the symptoms being manifested by JR. Thereafter, he ordered that JR be observed for 24 hours. However, the accused, as the attending physicians, did not personally monitor JR in order to check on subtle changes that may occur. Rather, they left the monitoring and actual observation to resident physicians who are just on residency training and in doing so, they substituted their own expertise, skill and competence with those of physicians who are merely new doctors still on training. Not having personally observed JR during this 24-hour critical period of observation, the accused relinquished their duty and thereby were unable to give the proper and correct evaluation as to the real condition of JR. In situations where massive infection is going on as shown by the aggressive medication of antibiotics, the condition of the patient is serious which necessitated personal, not delegated, attention of attending physicians, namely JR and the accused in this case.
x x x x
Throughout the course of the hospitalization and treatment of JR, the accused failed to address the acute appendicitis which was the initial diagnosis. They did not take steps to find out if indeed acute appendicitis was what was causing the massive infection that was ongoing inside the body of JR even when the inflammatory process was located at the paraumbilical region where the appendix can be located. x x x
There may have been other diseases but the records do not show that the accused took steps to find out what disease exactly was plaguing JR. It was their duty to find out the disease causing the health problem of JR, but they did not perform any process of elimination. Appendicitis, according to expert testimonies, could be eliminated only by surgery but no surgery was done by the accused. But the accused could not have found out the real disease of JR because they were treating merely and exclusively the symptoms by means of the different medications to arrest the manifested symptoms. In fact, by treating the symptoms alone, the accused were recklessly and wantonly ignoring the same as signs of the graver health problem of JR. This gross negligence on the part of the accused allowed the infection to spread inside the body of JR unabated. The infection obviously spread so fast and was so massive that within a period of only two and a half (2 ½) days from the day of admission to the hospital on June 15, 2000, JR who was otherwise healthy died [of] Septicemia (Acute Appendicitis) on June 17, 2000.11
The foregoing expert testimony clearly revealed such want of reasonable skill and care on the part of JR's attending physicians, appellants Dr. Cabugao and Dr. Ynzon in neglecting to monitor effectively and sufficiently the developments/changes during the observation period and act upon the situation after said 24-hour period when his abdominal pain subsisted, his condition even worsened with the appearance of more serious symptoms of nausea, vomiting and diarrhea. Considering the brief visit only made on regular rounds, the records clearly show such gross negligence in failing to take appropriate steps to determine the real cause of JR's abdominal pain so that the crucial decision to perform surgery (appendectomy) had even been ruled out precisely because of the inexcusable neglect to undertake such efficient diagnosis by process of elimination, as correctly pointed out by the trial court. As has been succinctly emphasized by Dr. Mateo, acute appendicitis was the working diagnosis, and with the emergence of symptoms after the 24-hour observation (high fever, vomiting, diarrhea) still, appellants ruled out surgery, not even considering exploratory laparoscopy. Dr. Mateo also expressed the opinion that the decision to operate could have been made after the result of the ultrasound test, considering that acute appendicitis was the initial diagnosis by Dr. Cabugao after he had conducted a rectal examination.
Medical records buttress the trial court's finding that in treating JR, appellants have demonstrated indifference and neglect of the patient's condition as a serious case. Indeed, appendicitis remains a clinical emergency and a surgical disease, as correctly underscored by Dr. Mateo, a practicing surgeon who has already performed over a thousand appendectomy. In fact, appendectomy is the only rational therapy for acute appendicitis; it avoids clinical deterioration and may avoid chronic or recurrent appendicitis. Although difficult, prompt recognition and immediate treatment of the disease prevent complications. Under the factual circumstances, the inaction, neglect and indifference of appellants who, after the day of admission and after being apprised of the ongoing infection from the CBC and initial diagnosis as acute appendicitis from rectal examination and ultrasound test and only briefly visited JR once during regular rounds and gave medication orders by telephone – constitutes gross negligence leading to the continued deterioration of the patient, his infection having spread in so fast a pace that he died within just two and a half (2 ½) days’ stay in the hospital. Authorities state that if the clinical picture is unclear a short period of 4 to 6 hours of watchful waiting and a CT scan may improve diagnostic accuracy and help to hasten diagnosis. Even assuming that JR's case had an atypical presentation in view of the location of his appendix, laboratory tests could have helped to confirm diagnosis, as Dr. Mateo opined that the possibility of JR having a retrocecal appendicitis should have been a strong consideration. Lamentably, however, as found by the trial court, appellants had not taken steps towards correct diagnosis and demonstrated laxity even when JR was already running a high fever in the morning of June 17, 2000 and continued vomiting with diarrhea, his abdominal pain becoming more intense. This is the reason why private complainants were not even apprised of the progress of appellants' diagnosis – appellants have nothing to report because they did nothing towards the end and merely gave medications to address the symptoms.12
WHETHER THE CAUSE OF ACCUSATION AS CONTAINED IN THE INFORMATION IS “FAILURE TO PERFORM IMMEDIATE OPERATION UPON THE PATIENT ROFOLFO PALMA JR. OF ACUTE APPENDICITIS;chanroblesvirtuallawlibrary
WHETHER THE SUBJECT INFORMATION APPEARS TO HAVE ACCUSED BOTH ACCUSED DOCTORS OF CONSPIRACY AND THE APPEALED DECISION SEEMS TO HAVE TREATED BOTH ACCUSED DOCTORS TO BE IN CONSPIRACY;chanroblesvirtuallawlibrary
WHETHER PETITIONER DR. CABUGAO IS A GENERAL PRACTITIONER (NOT A SURGEON) AND HAVE EXCLUDED SURGERY FROM THE LIMITS OF HIS PRACTICE, AND IT WAS NOT AND NEVER HIS DUTY TO OPERATE THE PATIENT RODOLFO PALMA JR., THAT WAS WHY HE REFERRED SUBJECT PATIENT TO A SURGEON, DR. CLENIO YNZON;chanroblesvirtuallawlibrary
WHETHER THE DEFENSE NEVER STATED THAT THERE IS GUARANTEE THAT DOING SURGERY WOULD HAVE SAVED THE PATIENT;chanroblesvirtuallawlibrary
WHETHER THE WITNESSES FOR THE PROSECUTION INCLUDING PROSECUTION'S EXPERT WITNESSES EVER DECLARED/TESTIFIED THAT PETITIONER DR. CABUGAO HAD THE DUTY TO PERFORM IMMEDIATE OPERATION ON RODOLFO PALMA, JR., AND THEY FAILED TO STATE/SHOW THAT THE PROXIMATE CAUSE OF DEATH OF JR WAS ACUTE APPENDICITIS;chanroblesvirtuallawlibrary
WHETHER THE EXPERT WITNESSES PRESENTED BY THE PROSECUTION EVER QUESTIONED THE MANAGEMENT AND CARE APPLIED BY PETITIONER DR. CABUGAO;chanroblesvirtuallawlibrary
WHETHER THE EXPERT WITNESSES PRESENTED BY THE DEFENSE ARE UNANIMOUS IN APPROVING THE METHOD OF TREATMENT APPLIED BY BOTH ACCUSED DOCTORS ON SUBJECT PATIENT, AND THEY DECLARED/AFFIRMED THAT THEY WOULD FIRST PLACE SUBJECT THE PATIENT UNDER OBSERVATION, AND WOULD NOT PERFORM IMMEDIATE OPERATION;chanroblesvirtuallawlibrary
WHETHER THE CONVICTION OF PETITIONER DR. YNZON WAS ESTABLISHED WITH THE REQUIRED QUANTUM OF PROOF BEYOND REASONABLE DOUBT THAT THE PATIENT WAS SPECIFICALLY SUFFERING FROM AND DIED OF ACUTE APPENDICITIS; andChanRoblesVirtualawlibrary
WHETHER THE FAILURE TO CONDUCT THE SPECIFIC SURGICAL OPERATION KNOWN AS APPENDECTOMY CONSTITUTED CRIMINAL NEGLIGENCE.
ATTY. CASTRO: Q. Given these data soft non-tender abdomen, ambulatory, watery diarrhea, Exhibit C which is the ultrasound result, with that laboratory would you operate the patient? A Yes, I would do surgery. Q And you should have done surgery with this particular case?” A Yes, sir.16 x x x x COURT: Q You stated a while ago doctor that you are going to [do] surgery to the patient, why doctor, if you are not going to do surgery, what will happen? A If this would be appendicitis, the usual progress would be that it would be ruptured and generalized peritonitis and eventually septicemia, sir. Q What do you mean by that doctor? A That means that infection would spread throughout the body, sir. Q If unchecked doctor, what will happen? A It will result to death.17
x x x x
Q And what would have you done if you entertain other considerations from the time the patient was admitted? A From the time the patient was admitted until the report of the sonologist, I would have made a decision by then. Q And when to decide the surgery would it be a particular exact time, would it be the same for all surgeons? A If you are asking acute appendicitis, it would be about 24 hours because acute appendicitis is a 24-hour disease, sir. Q. And would it be correct to say that it depends on the changes on the condition of the patient? A. Yes, sir. Q. So, are you saying more than 24 hours when there are changes? A. If there are changes in the patient pointing towards appendicitis then you have to decide right there and then, sir. Q. So if there are changes in the patient pointing to appendicitis? A. It depends now on what you are trying to wait for in the observation period, sir. Q. So precisely if the change is a condition which bring you in doubt that there is something else other than appendicitis, would you extend over a period of 24 hours? A. It depends on the emergent development, sir. Q. That is the point, if you are the attending physician and there is a change not pointing to appendicitis, would you extend over a period of 24 hours? A. In 24 hours you have to decide, sir. x x x x Q. And that is based on the assessment of the attending physician? A. Yes, sir.18
ATTY. CASTRO: Q: So you will know yourself, as far as the record is concerned, because if you will agree with me, you did not even touch the patient? A. Yes, I based my opinion on what is put on record, sir. The records show that after the observation period, the abdominal pain is still there plus there are already other signs and symptoms which are not seen or noted. Q. But insofar as you yourself not having touched the abdomen of the patient, would you give a comment on that? A. Yes, based on the record, after 24 hours of observation, the pain apparently was still there and there was more vomiting and there was diarrhea. In my personal opinion, I think the condition of the patient was deteriorating. Q. Even though you have not touched the patient? A. I based on what was on the record, sir.19
ATTY. CASTRO: Q. As an expert doctor, if you were faced with a history of abdominal pain with nausea, vomiting, fever, anurecia (sic), elevated white blood cell count, physical examination of a positive psoas sign, observation of the sonologist of abdominal tenderness and the ultrasound findings of the probability of appendiceal (sic) pathology, what will you do if you have faced these problems, Doctor? A. I will examine the patient thoroughly and it will depend on my physical examination and that is probably every 4 to 6 hours, sir.20
Cross Exam. By Atty. Marteja: Q. x x x However, there are corrections and admissions made at that time, your Honor, do I understand that T/C does not mean ruled out but rather to consider the matter? A. Yes, now that I have seen the records of the patient, it says here, impression and T/C means to consider the appendicitis. Q. Isn't it that it is worth then to say that the initial working diagnosis on Rodolfo Palma, Jr., otherwise known as JR, to whom I shall now refer to as JR, the primary consideration then is acute appendicitis, is that correct to say Doctor? A. I think so, that is the impression. Q. x x x Now if it is to be considered as the primary consideration in the initial working diagnosis, isn't it a fact that it has to be ruled out in order to consider it as not the disease of JR? A. Yes. Sir. Q. Isn't it a fact that to rule out acute appendicitis as not the disease of JR, surgery or operation must be done, isn't it Doctor? A. You have to correlate all the findings. Q. Is it yes or no, Doctor? A. Yes. Q. So, you are saying then that in order to rule out acute appendicitis there must be an operation, that is right Doctor? A. No, sir. If your diagnosis is to really determine if it is an acute appendicitis, you have to operate.21 x x x x Q. Now Doctor, considering the infection, considering that there was a [symptom] that causes pain, considering that JR likewise was feverish and that he was vomiting, does that not show a disease of acute appendicitis Doctor? A. Its possible. Q. So that if that is possible, are we getting the impression then Doctor what you have earlier mentioned that the only way to rule out the suspect which is acute appendicitis is by surgery, you have said that earlier Doctor, I just want any confirmation of it? A. Yes, sir.22
ATTY. MARTEJA: Q. You had mentioned that under this circumstances and condition, you have mentioned that surgery is the solution, would you have allowed then a 24 hour observation? A. If there is a lingering doubt, in short period of observation of 18-24 hours can be allowed provided that there would be close monitoring of the patient, sir. Q. Would you please tell us who would be doing the monitoring doctor? A. The best person should be the first examiner, the best surgeon, sir. Q. So that would you say that it is incumbent on the surgeon attending to the case to have been the one to observe within the period of observation? A. Yes, because he will be in the best position to observe the sudden changes in the condition of the patient, sir. Q. And how often would in your experience doctor, how often would the surgeon re-assist (sic) the condition of the patient during the period of observation? A. Most foreign authors would recommend every four (4) hours, some centers will recommend hourly or every two hours but here in the Philippines, would recommend for 4 to 6 hours, sir.28
Q. Isn't it a fact that to rule out acute appendicitis as not the disease of JR, surgery or operation must be done, isn't it Doctor? A. You have to [correlate] all the findings. Q. Is it yes or no, Doctor? A. Yes. Q. So, you are saying then that in order to rule out acute appendicitis there must be an operation, that is right Doctor? A. No, sir. If your diagnosis is to really determine if it is an acute appendicitis, you have to operate.29 x x x x Q. Now Doctor, considering the infection, considering that there was a [symptom] that causes pain, considering that JR likewise was feverish and that he was vomitting, does that not show a disease of acute appendicitis Doctor? A. It’s possible. Q. So that if that is possible, are we getting the impression then Doctor what you have earlier mentioned that the only way to rule out the suspect which is acute appendicitis is by surgery, you have said that earlier Doctor, I just want any confirmation of it? A. Yes, sir.30
1. Death of the accused pending appeal of his conviction extinguishes his criminal liability as well as the civil liability based solely thereon. As opined by Justice Regalado, in this regard, "the death of the accused prior to final judgment terminates his criminal liability and only the civil liability directly arising from and based solely on the offense committed, i.e., civil liability ex delicto in senso strictiore."
2. Corollarily, the claim for civil liability survives notwithstanding the death of accused, if the same may also be predicated on a source of obligation other than delict. Article 1157 of the Civil Code enumerates these other sources of obligation from which the civil liability may arise as a result of the same act or omission:a) Law3. Where the civil liability survives, as explained in Number 2 above, an action for recovery therefor may be pursued but only by way of filing a separate civil action and subject to Section 1, Rule 111 of the 1985 Rules on Criminal Procedure as amended. This separate civil action may be enforced either against the executor/administrator or the estate of the accused, depending on the source of obligation upon which the same is based as explained above.
d) x x x x x x x x x
4. Finally, the private offended party need not fear a forfeiture of his right to file this separate civil action by prescription, in cases where during the prosecution of the criminal action and prior to its extinction, the private-offended party instituted together therewith the civil action. In such case, the statute of limitations on the civil liability is deemed interrupted during the pendency of the criminal case, conformably with provisions of Article 1155 of the Civil Code, that should thereby avoid any apprehension on a possible privation of right by prescription.35
Sec. 4. Effect of death on civil actions. – The death of the accused after arraignment and during the pendency of the criminal action shall extinguish the civil liability arising from the delict. However, the independent civil action instituted under section 3 of this Rule or which thereafter is instituted to enforce liability arising from other sources of obligation may be continued against the estate or legal representative of the accused after proper substitution or against said estate, as the case may be. The heirs of the accused may be substituted for the deceased without requiring the appointment of an executor or administrator and the court may appoint a guardian ad litem for the minor heirs.
The court shall forthwith order said legal representative or representatives to appear and be substituted within a period of thirty (30) days from notice.
A final judgment entered in favor of the offended party shall be enforced in the manner especially provided in these rules for prosecuting claims against the estate of the deceased.
If the accused dies before arraignment, the case shall be dismissed without prejudice to any civil action the offended party may file against the estate of the deceased. (Emphases ours)chanrobleslaw
Section 1. Actions which may and which may not be brought against executor or administrator. — No action upon a claim for the recovery of money or debt or interest thereon shall be commenced against the executor or administrator; but to recover real or personal property, or an interest therein, from the estate, or to enforce a lien thereon, and actions to recover damages for an injury to person or property, real or personal, may be commenced against him. (Emphases ours)
Section 5. Claims which must be filed under the notice. If not filed, barred; exceptions. — All claims for money against the decent, arising from contract, express or implied, whether the same be due, not due, or contingent, all claims for funeral expenses and expense for the last sickness of the decedent, and judgment for money against the decent, must be filed within the time limited in the notice; otherwise they are barred forever, except that they may be set forth as counterclaims in any action that the executor or administrator may bring against the claimants. Where an executor or administrator commences an action, or prosecutes an action already commenced by the deceased in his lifetime, the debtor may set forth by answer the claims he has against the decedent, instead of presenting them independently to the court as herein provided, and mutual claims may be set off against each other in such action; and if final judgment is rendered in favor of the defendant, the amount so determined shall be considered the true balance against the estate, as though the claim had been presented directly before the court in the administration proceedings. Claims not yet due, or contingent, may be approved at their present value.
* Designated Acting Member, per Special Order No. 1691-L dated May 22, 2014, in view of the vacancy in the Third Division.
1 Penned by Associate Justice Martin S. Villarama, Jr. (now a member of the Supreme Court), with Associate Justices Regalado E. Maambong and Lucenito N. Tagle, concurring; rollo, (G.R. No. 163879), pp. 25-46.
2Rollo, (G.R. No. 165805), pp. 106-112.
3 Id. at 103-104.
4 Resolution dated August 2, 2006; id. at 611.
5Rollo (G.R. No. 163879), p. 26.
6 Exhibit “C,” records, p. 23. (Emphasis ours)
7 Exhibit “D-2,” id. at 331.
8Rollo, p. 27.
9 Pre-trial Order; records, p. 181.
10 Exhibit “E,” id. at 6.
11Rollo (G.R. No. 165805), pp. 110-111.
12Rollo (G.R. No. 163879), pp. 44-45. (Citations omitted; italics in the original)
13 Gaid v. People, G.R. No. 171636, April 7, 2009, 584 SCRA 489, 495.
14Dr. Cruz v. Court of Appeals, 346 Phil. 872, 883 (1993).
15 The prosecution has presented Dr. Antonio Mateo as an expert witness having performed more than a thousand appendectomy in his seventeen (17) years as a practicing surgeon and holds the position of Chief of the Department of Surgery of the Rizal Provincial Hospital and a Regular Fellow of the Philippine College of Surgeons.
16 TSN, June 29, 2001, p. 68. (Emphases ours)
17 Id. at 69. (Emphases ours)
18 Id. at 73-74. (Emphasis ours)
19 TSN, July 18, 2001, p. 11. (Emphases ours)
20 TSN (Dr. Vivencio Villaflor, Jr.), September. 7, 2001, p. 17. (Emphasis ours)
21 TSN (Dr. V. Villaflor, Jr.), March 20, 2002, pp. 4-5. (Emphases ours)
22 Id. at 17. (Emphases ours)
23Dr. Cruz v. Court of Appeals, supra note 14, at 885.
24Caminos, Jr. v. People, 605 Phil. 402, 435 (2009).
25 Ivler v. Modesto-San Pedro, G.R. No. 172716, November 17, 2010, 635 SCRA 191, 223.
26Garcia-Rueda v. Pascasio, 344 Phil. 323, 332 (1997).
27 Annex “D-13,” records, p. 39.
28 TSN, June 29, 2001, pp. 35-36. (Emphasis ours)
29 TSN, (Dr. Vivencio Villaflor, Jr.), March 20, 2002, p. 5.
30 Id. at 17.
31 See Jarcia, Jr. v. People, G.R. No. 187926, February 15, 2012, 666 SCRA 336, 358.
32Villareal v. People, G.R. No. 151258, G.R. No. 154984, G.R. No. 155101, G.R. Nos. 178057 and 178080, February 1, 2012, 664 SCRA 519, 559.
33Rollo (G.R. No. 163879), pp. 303-307.
34 G.R. No. 102007, September 2, 1994, 236 SCRA 239.
35People v. Bayotas, supra, at 255-256. (Citations omitted; emphases ours.)
36 See People v. Abungan, 395 Phil. 456, 461 (2000).
37 2000 Rules on Criminal Procedure, as amended.
38People v. Bayotas, supra note 30, at 254.
39 See Maniego v. Court of Appeals, 324 Phil. 34, 39 (1996).