Medical professionals and healthcare providers are mandated to accord primordial consideration to the health and welfare of their patients. Should they fail to exercise the required degree of prudence, they shall be held accountable for their actions, as they hold in their hands the life and death of those entrusted to their care.

This is a Petition for Review on Certiorari^[1] under Rule 45 of the Rules of Court filed by Eleanor Reyno (Reyno) and Elsa De Vera (De Vera), assailing the Decision^[2] dated June 28, 2016 and the Resolution^[3] dated September 20, 2016 of the Court of Appeals (CA) in CA-G.R. CV No. 105915. The CA Decision affirmed in part the Decision^[4] dated April 29, 2015 of the Regional Trial Court, Branch 35, Santiago City (RTC) insofar as the other defendants are concerned, but held both Reyno and De Vera jointly and severally liable for damages.

Antecedents

George Baltazar (George) and Joel Baltazar (Joel) are the husband and son, respectively, of Teresita Laurena Baltazar (Teresita). Teresita was a diabetic patient of Dr. Jade P. Malvar (Dr. Malvar), a physician holding clinic hours at Callang's General Hospital (CGH).^[5] Teresita was referred to Dr. Malvar for a wound on her left foot. Upon examination, Dr. Malvar advised that she undergo debridement, a minor and superficial procedure to thoroughly clean the wound.^[6] Due to financial constraints, Dr. Malvar suggested that Teresita transfer to a government hospital, Echague District Hospital (EDH). Following Dr. Malvar's advice and upon his written orders, Teresita was transferred to the EDH on June 9, 2009, between 8:00 p.m. and 9:00 p.m., in time for her scheduled surgery the following day.^[7] As part of Teresita's treatment being a diabetic patient, Dr. Malvar consulted a specialist, Dr. Cabucana De Guzman (Dr. De Guzman),^[8] who instructed, among others, that Teresita be administered insulin during certain times of the day, particularly at 6:00 a.m., 12:00 n.n., 6:00 p.m., and 12:00 m.n.,^[9] to manage her diabetes during the course of the procedure. Further, Dr. De Guzman required that a Random Blood Sugar (RBS) test be done prior to each insulin injections.^[10]

The aforesaid instructions were specifically left to the nurses on ward duty, namely, Gigi Tomas (Tomas), designated as the ward nurse on duty from 12 m.n. to 8:90 a.m.;^[11] De Vera, on duty from 8:00 a.m. to 4:00 p.m.;^[12] and Reyno, on duty from 4:00 p.m. to 12:00 m.n.^[13]

On June 10, 2009, at 10:30 a.m., George and Joel visited Teresita, who seemed to be in high spirits. At 11:15 a.m., Tomas endorsed Teresita to De Vera,^[14] who administered insulin to Teresita at 11:30 a.m.^[15] Thereafter, Dr. Malvar, along with anesthesiologist Dr. Baby Delfin L. Cabansag (Dr. Cabansag), performed the debridement, which ended at 12:20 n.n. without any complications.^[16] After the operation, Teresita was assigned to recover in the ward while De Vera was still on duty. When De Vera's shift ended at 4:00 p.m., she endorsed Teresita to the care of the incoming nurse, Reyno.^[17]

At 5:00 p.m., Joel visited his mother. At 5:20 p.m., Reyno, as the ward nurse on duty, administered insulin to Teresita.^[18] After about an hour, Reyno came by the room and proceeded to remove the oxygen mask attached to Teresita.^[19] Despite Joel's protestations, Reyno informed him that the hospital was short of oxygen masks and that another patient also needed it. Considering Teresita's stable condition, she sought permission from Dr. Cabansag to remove her oxygen mask.^[20]

Moments later, Teresita's health took a turn for the worse, as Joel noticed that she was having difficulty breathing. He rushed to find Reyno to inform her of Teresita's condition, and to inquire as to the removal of his mother's oxygen mask. Reyno retorted in a defensive manner, saying "wala akong kinakatakutan ... kahit magsumbong ka sa mga taga hospital."^[21] Despite her reaction, Reyno immediately returned the oxygen mask and attached it to Teresita.^[22]

After a while, Reyno observed that Teresita's difficulty in breathing persisted, and worse, she was beginning to salivate. Alarmed, she immediately called Dr. Malvar regarding the status of his patient. Dr. Malvar instructed that she administer a "fifty-fifty intravenous" to Teresita.^[23] When Teresita's blood pressure began to fluctuate, Reyno called Dr. Malvar a second time and sought the help of the resident physician on duty, Dr. Honorio I. Caramancion (Dr. Caramancion), to attend to Teresita in the interim.^[24] As an emergency measure, Dr. Caramancion administered epinephrine to stimulate cardiac activity.^[25] Upon checking Teresita's heartbeat and pulse rate, Dr. Caramancion noticed that she was already unresponsive, causing him to declare her dead. Shortly thereafter, Dr. Malvar arrived and attempted to resuscitate her, but to no avail. Teresita was pronounced dead at 7:00 p.m.^[26]

Believing that Teresita's death was caused by the negligent and erroneous acts of the EDH and its staff, George and Joel instituted an action for damages against the local government of the province of Isabela (Isabela) as employer of the EDH personnel, Dr. Ma. Cristina A. Ventura (Dr. Ventura) as the officer-in-charge of the EDH, Dr. Caramancion, and nurses Reyno and De Vera before the RTC.^[27]

In a Decision^[28] dated April 29, 2015, the RTC dismissed the instant complaint for lack of merit, the decretal part of which states:

WHEREFORE, for lack of merit, the instant case is hereby DISMISSED. No other pronouncement.

SO ORDERED.^[29]

In dismissing the complaint, the RTC held that the cause of Teresita's death was not clearly established, as there was no autopsy conducted to conclusively identify the exact cause of her death.^[30]

More, it was convinced that there was no negligence on the part of the EDH and it staff in attending to Teresita. The RTC ruled that Dr. Caramancion could not be held liable as he was merely the physician on duty and was not even Teresita's attending physician. He was also not involved in the debridement procedure earlier that day. Thus, the RTC assessed that he was only responsible for responding to an emergency situation, during which he acted promptly and with necessary due care.^[31]

It also ruled that Reyno and De Vera cannot be faulted in the performance of their duties. The RTC acknowledged that prior to removing the oxygen mask from Teresita, Reyno ensured that her vital signs were stable and that there was prior clearance from one of her doctors, Dr. Cabansag. Moreover, upon noticing Teresita's difficulty in breathing, she acted with haste and attached the oxygen immediately. Further, during Dr. Caramancion's attempt to revive Teresita, she exerted due efforts in keeping Dr. Malvar abreast as to the status of his patient, and thereafter, asked him to rush to the hospital.^[32]

With regard to De Vera, the RTC observed that she had properly endorsed Teresita to Reyno after her shift had ended. Assuming that she had failed to endorse the conduct of a random blood sugar test (RBS test) prior to the administration of insulin as instructed, there was no showing that such failure caused Teresita's untimely death.^[33] As to Dr. Ventura, the RTC exculpated her from liability as she was away on official business at the time of the incident. Moreso, there was nothing irregular in the exercise of her duties as she immediately conducted an investigation surrounding the death of Teresita.^[34]

Finally, the RTC was not persuaded with regard to the liability of the province of Isabela. Having adjudged that the cause of Teresita's death was not established, the presumption of fault or negligence on the part of Isabela, as employer, did not even arise. Hence, the RTC felt no need to delve into its defense that it had exercised due diligence in the selection and supervision of its employees.^[35]

Aggrieved, George and Joel sought reconsideration,^[36] which was denied in an Order^[37] dated July 30, 2015. Thus, they interposed an appeal^[38] before the CA.

In its Decision^[39] dated June 28, 2016, the CA partially granted the appeal. While it relieved Isabela, Dr. Ventura, and Dr. Caramancion from liability, it held both Reyno and De Vera jointly and severally liable for damages. The CA disposed in this wise:

WHEREFORE, premises considered, the instant appeal is partly GRANTED. The assailed Decision dated April 29, 2015 and Order dated July 30, 2015 of the RTC, Branch 35, Santiago City, Isabela in Civil Case No. 35-3595 are hereby AFFIRMED insofar as defendants-appellees LGU, Isabela, Maria Christina A. Ventura, Dr. Honorio Caramancion are concerned. However, defendants-appellees Eleanor Reyno and Elsa De Vera are hereby declared JOINTLY AND SEVERALLY LIABLE to pay plaintiffs-appellants George and Joel Baltazar the amount of P28,690.00 as actual damages, P50,000.00 as civil indemnity, P200,000.00 as moral damages, P100,000.00 as exemplary damages, and P50,000.00 as attorney's fees.

SO ORDERED.^[40]

The CA applied the doctrine of res ipsa loquitur in finding Reyno and De Vera liable for Teresita's death due to their negligence in the performance of their duties.^[41] First, it was admitted that Teresita died on June 10, 2009, less than 24 hours after being admitted at the EDH, and subsequent to undergoing a very simple operation. Second, as death could not have resulted from the minor operation, Reyno and De Vera's intervening negligent acts ultimately caused her death.^[42] Hospital records prove that Teresita was injected with insulin without an RBS test as required by the doctors' preoperation orders, thus, exposing the patient to the risk of contracting hypoglycemia, which could cause death.^[43] To compound this oversight, Teresita was not given any food since the day before her operation until the time of her death, contrary to the doctors' instructions.^[44] Third, based on the totality of circumstances, the untimely death of Teresita could have been caused by hypoglycemia which appears to be linked to the cause of death as indicated in Teresita's certificate of death. Finally, the doctors' orders were clear, straightforward, and were under the exclusive control of Reyno and De Vera. As the nurses charged with Teresita's care, it was incumbent upon them to abide by such instructions. For failure to do so, they must be held liable for damages.

Reyno and De Vera sought for reconsideration,^[45] assailing the Decision on procedural grounds. They principally argue that the Decision dated April 29, 2015 of the RTC had already attained finality, as the motion for reconsideration filed by George and Joel Baltazar lacked notice of hearing, thus, depriving them of the opportunity to be heard. Consequently, it may not have the effect of tolling the period to file an appeal, thus allowing the RTC Decision to lapse into finality.^[46]

In its Resolution^[47] dated September 20, 2016, the CA denied the motion for reconsideration for lack of merit, citing Jehan Shipping Corporation v. National Food Authority^[48] wherein this Court laid down the rule that the requirement of procedural due process is not per se violated due to the failure to comply with the notice requirement in a motion. So long as parties are given the opportunity to be heard, as well as time to study the motion and meaningfully oppose or controvert the same, the requirements of procedural due process are considered complied with. In the instant case, considering that Reyno and De Vera were able to file a comment/opposition to object George and Joel's motion for reconsideration, there is no gainsaying that they were not totally deprived of the opportunity to be heard. As George and Joel are deemed to have substantially complied with the rules of procedural due process, there was nothing erroneous in giving due course to their motion.^[49]

Hence, the instant Petition.

On procedural grounds, Reyno and De Vera reiterated that the CA erred in its finding that the omission of a notice of hearing in the motion for reconsideration of George and Joel did not prove fatal in complying with the requirements of due process. They insist that the RTC Decision already became final and executory, as the motion for reconsideration did not suspend the running of the prescriptive period to file an appeal.^[50] As to the merits, Reyno and De Vera advance the view that George and Joel failed to establish by evidence the elements of a medical negligence case on the ground that Teresita was not autopsied so as to ascertain the exact cause of her death.^[51]

In their Comment,^[52] George and Joel assert that the grounds raised by Reyno and De Vera are a mere rehash of those already passed upon by the CA.^[53] Nevertheless, they assert that given the negligence of Reyno and De Vera as found by the CA, the principle of res ipsa loquitur is applicable in this case.^[54] More, given that the question of negligence is a question of fact, such issues may no longer be questioned in a petition for review on certiorari.^[55]

Reyno and De Vera filed a Reply^[56] to George and Joel's Comment. They principally aver that the doctrine of res ipsa loquitur bears no applicability in this case. Particularly, the order to conduct an RBS test was an order prior to the operation of the patient and that the same was never ordered by Dr. Malvar after Teresita's operation. More, it was never conclusively found that the failure to carry out such an order was the cause of Teresita's death. Thus, her death may be attributed to a lot of causes, which was never established by preponderance of evidence.^[57]

The Issues

First, whether the CA erred in its finding that the motion for reconsideration of respondents George Baltazar and Joel Baltazar without notice of hearing substantially complied with the requirements of procedural due process; and

Second, whether the CA erred in its application of the doctrine of res ipsa loquitur in finding that petitioners Eleanor Reyno and Elsa De Vera's negligence caused the death of Teresita.^[58]

Our Ruling

The Petition lacks merit. This Court shall proceed to address the issues in seriatim.

I.

This Court sustains the CA ruling on the first issue. The CA did not err in its finding that the motion for reconsideration filed by respondents in the RTC substantially complied with the requirements of procedural due process, even absent notice of hearing.

Preliminarily, it has been held time and again that the notice requirement for motions, which shall be directed to the parties concerned, and shall state the time and place for the hearing, is mandatory in nature.^[59] This principle is embodied in the express wording of Section 5, Rule 15 of the 1997 Rules on Civil Procedure, which states:

Section 5. Notice of hearing. — The notice of hearing shall be addressed to all parties concerned, and shall specify the time and date of the hearing which must not be later than ten (10) days after the filing of the motion. (5a)

In Jehan Shipping Corporation v. National Food Authority,^[60] this Court was given the opportunity to clarify the rule, which at present is neither fixed nor absolute. In Jehan, respondent National Food Authority (NFA) committed a procedural lapse in failing to include a notice of hearing in its motions for reconsideration. As a result, petitioner Jehan Shipping Corporation (Jehan) averred that the RTC Decision decided in its favor should be declared final and executory, as the motions did not have legal effect for failure to adhere to the rules.

In ruling for the NFA, this Court held that the omission of a notice of hearing does not prove fatal to the motions if the adverse party actually had the opportunity to be heard, pursuant to the rules of procedural due process. Here, Jehan was able to ventilate its substantial arguments against the motions in its opposition to the motions. For having been afforded the opportunity to assail NFA's motions for reconsideration, this Court concluded that the purpose of a notice of hearing, which is to apprise the other of the actions of the former, was served in this case. This Court further elaborated on the rationale behind the notice requirement in this wise:

The test is the presence of the opportunity to be heard, as well as to have time to study the motion and meaningfully oppose or controvert the grounds upon which it is based. Considering the circumstances of the present-case, we believe that the requirements of procedural due process were substantially complied with, and that the compliance justified a departure from a literal application of the rule on notice of hearing.

x x x x

A close perusal of the records reveals that the trial court gave petitioner ten days within which to comment on respondent's Motion for Reconsideration. Petitioner filed its Opposition to the Motion on November 26, 2001. In its 14-page Opposition, it not only pointed out that the Motion was defective for not containing a notice of hearing and should then be dismissed outright by the court; it also ventilated its substantial arguments against the merits of the Motion and of the Supplemental Motion for Reconsideration. Notably, its arguments were recited at length in the trial court's January 8, 2002 Joint Resolution. Nevertheless, the court proceeded to deny the Motions on the sole ground that they did not contain any notice of hearing.

The requirement of notice of time and hearing in the pleading filed by a party is necessary only to apprise the other of the actions of the former. Under the circumstances of the present case, the purpose of a notice of hearing was served.^[61]

The principle explained in Jehan was later reiterated in Preysler, Jr. v. Manila Southcoast Development Corporation,^[62] where this Court expressed that "a liberal construction of the procedural rules is proper where the lapse in the literal observance of a rule of procedure has not prejudiced the adverse party and has not deprived the court of its authority."^[63]

Similarly, in City of Dagupan v. Maramba,^[64] this Court excused the lack of a notice of hearing in petitioner's motion for reconsideration as respondent was able to file an opposition on the ground that the motion was not set for hearing. In liberally construing procedural rules in favor of substantial justice, this Court invoked the ruling in Sy v. Local Government of Quezon City,^[65] to wit:

Be that as it may, procedural rules may, nonetheless, be relaxed for the most persuasive of reasons in order to relieve a litigant of an injustice not commensurate with the degree of his thoughtlessness in not complying with the procedure prescribed. Corollarily, the rule, which states that the mistakes of counsel bind the client, may not be strictly followed where observance of it would result in the deprived deprivation of the client's liberty or property, or where the interest of justice so requires.^[66]

The foregoing disquisitions apply squarely to the facts of the instant case. Predicated on these rulings, respondents' misstep is excusable in the interest of justice. Records prove that petitioners were given the opportunity to file a comment/opposition^[67] on the motion for reconsideration lodged by respondents in the RTC. If that was not enough, they were afforded the chance to file another comment/opposition,^[68] this time, on the notice of appeal lodged by respondents. It bears stressing that in both Comment/Oppositions, which were duly passed upon by the RTC, petitioners had already raised the argument that respondents' motions were defective and, thus, should be dismissed outright. For invoking that same argument in the CA and even before this forum, there is no quibbling that petitioners have already exhausted their recourse. Given the numerous chances to thresh out their case, the departure from the strict application of the rule on notice of hearing is more than justified. This Court quotes with approval the following portions of the assailed CA resolution:

Here, it bears emphasizing that defendants-appellees [petitioners] were able to file their Comment/Opposition dated July 13, 2015 to object to plaintiff-appellants' [respondents] June 26, 2015 Motion for Reconsideration. As such, there is no gainsaying that defendants-appellees were not totally deprived of the opportunity to be heard and to meaningfully oppose or controvert the arguments laid down in the said Motion for Reconsideration. Therefore, with such compelling circumstance, plaintiffs-appellants are deemed to have substantially complied with the aforementioned procedural rule on notice of hearing.^[69]

Withal, the purpose behind the required notice of hearing — "to provide the time to study the motion for reconsideration and give an opportunity to be heard"^[70] — was satisfied in this case. As held in Republic v. Department of Public Works and Highways,^[71] "the denial of due process cannot be successfully invoked by a party who was afforded the opportunity to be heard[.]"^[72]

Lastly, this Court further points out that pursuant to the Amended Rules on Civil Procedure,^[73] there is no longer a requirement for motions to contain a notice of hearing. As it stands, it is the court, in the exercise of its discretion, who shall deem it necessary to call a hearing on the motion. More particularly, Section 6, Rule 15 thereof states:

Section 6. Notice of hearing on litigious motions; discretionary. — The court may, in the exercise of its discretion, and if deemed necessary for its resolution, call a hearing on the motion. The notice of hearing shall be addressed to all parties concerned, and shall specify the time and date of the hearing. (5)

II.

On the merits, this Court likewise sustains the CA in its application of the doctrine of res ipsa loquitur to hold petitioners jointly and severally liable for the death of Teresita.

Critical to the resolution of this case is a clear understanding of the doctrine of res ipsa loquitur, a latin maxim to mean "the thing or the transaction speaks for itself," or in the vernacular, "isang bagay na nangungusap na sa kanyang sarili."^[74] With its basic underpinning in Roman law, the phrase made its way in American jurisprudence. In the 1835 case of Bank of United States v. Waggoner,^[75] the United States Supreme Court resolved the issue of when a contract would be considered usurious. It upheld the construction in English law that to constitute usury, there must be an intention knowingly to contract for or to take usurious interest, such that if neither party intends it nor acts innocently, the law will not infer a corrupt agreement. In contrast, when the contract, on its face, imports usury, as by an express rate that is over and above the stipulated legal interest, the intent to commit usury is apparent, res ipsa loquitur. Eventually, the doctrine was clearly laid down in the 1865 English case of Scott v. London & St. Katherine Docks Co.^[76] by then Chief Justice William Erle, to wit:

There must be reasonable evidence of negligence. But where the thing is shown to be under the management of the defendant or his servants, and the accident is such as in the ordinary course of things does not happen if those who have the management use proper care, it affords reasonable evidence, 'in the absence of explanation by the defendants, that the accident arose from want of care.^[77]

The doctrine of res ipsa loquitur eventually reached Philippine shores, with its application hewing closely to its Anglo-American context. In Africa, et al. v. Caltex (Phils.), Inc., et al.,^[78] this Court, in applying the doctrine of res ipsa loquitur, interestingly quoted Espiritu v. Philippine Power and Development Co.,^[79] a 1949 CA ruling, penned by then CA Justice J.B.L. Reyes, who eventually became a member of this Court. The salient portions as cited in Africa read:

The first point is directed against the sufficiency of plaintiff's evidence to place appellant on its defense. While it is the rule, as contended by the appellant, that in case of noncontractual negligence, or culpa aquiliana, the burden of proof is on the plaintiff to establish that the proximate cause of his injury was the negligence of the defendant, it is also a recognized principle that "Where the thing which caused injury, without fault of the injured person, is under the exclusive control of the defendant and the injury is such as in the ordinary course of things does not occur if those having such control use proper care, it affords reasonable evidence, in the absence of the explanation that the injury arose from defendant's want of care."

And the burden of evidence is shifted to him to establish that he has observed due care and diligence. (San Juan Light & Transit Co. vs. Requena, 224 U.S. 89, 56 L. ed. 68). This rule is known by the name of res ipsa loquitur (the transaction speaks for itself), and is peculiarly applicable to the case at bar, where it is unquestioned that the plaintiff had every right to be on the highway, and the electric wire was under the sole control of defendant company. In the ordinary course of events, electric wires do not part suddenly in fair weather and injure people, unless they are subjected to unusual strain and stress or there are defects in their installation, maintenance and supervision; just as barrels do not ordinarily roll out of the warehouse windows to injure passersby unless some one (sic) was negligent. (Byrne vs. Boadle, 2 H & Co. 22; 159 Eng. Reprint 299, the leading case that established that rule). Consequently, in the absence of contributory negligence (which is admittedly not present) the fact that the wire snapped suffices to raise a reasonable presumption of negligence in the installation, care and maintenance. Thereafter, as observed by Chief Baron Pollock, if there are any facts inconsistent with negligence, it is for the defendant to prove. x x x^[80]

Since then, the doctrine has evolved and is practically of jurisprudential creation. At present, the doctrine is a matter of evidence and is not a rule of substantive law; neither does it create or constitute an independent or separate ground of liability. It is recognized as a "mode of proof, of a mere procedural convenience since it furnishes a substitute for, and relieves a plaintiff of, the burden of producing specific proof of negligence."^[81] As a rule of necessity, the doctrine applies in cases wherein evidence is absent or not even readily available.^[82] Thus, it permits the plaintiff to "present, along with proof of the accident, enough of the attending circumstances to invoke the doctrine, create an inference or presumption of negligence, and thereby place on the defendant the burden of proving that there was no negligence on his part."^[83]

A resort to the doctrine is allowable only upon a satisfactory showing of the following elements:

(1) The accident was of such character as to warrant an inference that it would not have happened except for the defendant's negligence; (2) The accident must have been caused by an agency or instrumentality within the exclusive management or control of the person charged with the negligence complained of; and (3) The accident must not have been due to any voluntary action or contribution on the part of the person injured.^[84]

In Ramos v. Court of Appeals,^[85] this Court, making reference to the US case of St. John's Hospital School of Nursing v. Chapman,^[86] underscored that the fundamental element is the "control of the instrumentality" which caused the damage. Necessarily, it is incumbent upon the plaintiff to show that the element of control was within the dominion of the defendant.^[87]

Pertinent to the instant case, the doctrine is most commonly applied in medical negligence cases. In such cases, the application of res ipsa loquitur involves a question of law, considering that the determination of whether a certain set of circumstances permit a given inference is distinct judicial function.^[88] When the doctrine is appropriate, all that is required of the patient or the complaining party is to "prove a nexus between the particular act or omission complained of and the injury sustained while under the custody and management of the defendant without need to produce expert medical testimony to establish the standard of care."^[89]

As a further requirement, the doctrine may not be raised when the defendant's alleged failure to observe due care is not immediately apparent to a layman.^[90] As a matter of course, the doctrine was applied in the following cases: (1) when a woman, upon giving birth, suffered from a fresh gaping wound close to her armpit due to a droplight;^[91] (2) when a patient scheduled for the removal of gallstones suffered irreversible brain damage due to anesthesia prior to the operation;^[92] (3) when the operating surgeon left pieces of her rubber gloves while performing a simple caesarean section, causing the patient to suffer from ovarian cysts and severe infection;^[93] and (4) when a physician knowingly used incorrect screws to fix a jaw fracture, thus disabling the patient to properly open and close his mouth due to pain.^[94]

Upon careful consideration, what is at once evident in the instant case is the presence of all the elements for the application of the doctrine of res ipsa loquitur.

To recapitulate, Teresita submitted herself for debridement, expecting a routine operation on her left foot. While she was transferred to the EDH due to financial constraints, she had obtained prior clearance from her main physician, Dr. Malvar. On that fateful day, respondents were with her prior to the operation, even reporting that she was in high spirits. The procedure, which lasted for a little over an hour, was a success and was without any complications. Discernibly, there was nothing amiss with the performance of the duties of Drs. Malvar and Cabansag as Teresita's physicians. As testified by De Vera herself, Teresita was healthy and exhibited good vital signs after her operation.^[95] Indubitably, the death of a patient is one that does not occur under normal circumstances following the process of a debridement. Elsewise stated, the success of the operation, which involved a mere superficial cleaning of a foot wound,^[96] and her supposed recovery, thereafter, could not have led to the death of Teresita, unless negligence had set in somewhere.

Similarly apparent in this case was the stark deterioration of Teresita's health during the time that she was turned over to the exclusive care and control of petitioners as a patient in their ward. As ward nurses, De Vera attested that they were charged, among others, with carrying out doctor's orders, administering all prescribed medicines and treatments, and answering to all the needs and complaints of the patients specifically assigned to their ward.^[97] Indeed, records bear out that prior to her operation, up until the circumstances leading to her death, Teresita's pre- and post-operation treatments, including, among others, the administration of her medicine and tests, were under the immediate and exclusive management of petitioners. Significantly, after the operation and until her untimely demise, Teresita was left to the care of petitioners, and not her physicians, who were not even in the hospital at such time.

Finally, Teresita could not, by any stretch of the imagination, have contributed to her death. It must be pointed out that after her operation, Teresita still remained dependent on the petitioners for post-operation treatments. Given her condition, evidence is wanting to prove that Teresita committed any act that would impair her recovery, or worse, lead to her death.

This Court hastens to add that the present case is similar to the situation contemplated in Ramos to determine the appropriateness of res ipsa loquitur, wherein a "layman is able to say, as a matter of common knowledge and observation, that the consequences of professional care were not as such as would ordinarily have followed if due care had been exercised."^[98] Surely, the resulting death of Teresita was an untoward consequence that even the respondents, who possessed no technical medical knowledge, could easily and logically arrive at the conclusion that death would not be the likely outcome in the treatment of a minor procedure.

As all the elements for recourse to the doctrine of res ipsa loquitur are present, this Court now turns to whether petitioners were negligent in the care of Teresita, and if in the affirmative, whether such alleged negligence was the proximate cause of her eventual death.

This Court rules in the affirmative. Teresita's Certificate of Death^[99] indicate that she died from the following:

Immediate Cause: Metabolic Encephalopathy versus Myocardial Infarction
Antecedent Cause: Hypoglycemia versus Myocardial Infarction
Underlying Cause: Probably Hypoglycemia versus Myocardial Infarction.

Here, petitioners' contention that the death certificate is suspect fails to merit consideration. As established in Philam Life Insurance Company v. Court of Appeals,^[100] death certificates "are prima facie evidence of facts therein stated. A duly-registered death certificate is considered a public document and the entries found therein are presumed correct, unless the party who contests its accuracy can produce positive evidence establishing otherwise." Accordingly, the CA correctly relied on Teresita's Certificate of Death in determining petitioners' liability. After all, most especially in res ipsa loquitur cases where evidence is not readily available or apparent, such records are helpful in furnishing not only the logical scientific evidence of the patient's death, but also in providing its nexus to the liability of those responsible.

On this score, the testimony of Dr. Malvar illumines on the connection between the indicated causes of death in Teresita's death certificate vis-à-vis the negligence of petitioners. In the main, he attests that petitioners were remiss in the discharge of their duties for injecting insulin into the system of Teresita without the necessary RBS test, thereby causing her to develop hypoglycemia, a condition that could be life-threatening for diabetes patients if left untreated.

Understandably, the CA had every reason to anchor petitioners' culpability on the declarations of Dr. Malvar, who was Teresita's personal physician, being the one who ordered all her pre- and post- operative treatments, as well as having prepared her Certificate of Death. Given his medical qualifications and proximity to Teresita, there is no question that his testimony would serve to amply enlighten this Court regarding the technical procedures and its implications in pinpointing the cause of Teresita's death. Concededly, while Dr. Malvar admits that he is not a specialist in terms of diabetes mellitus, this Court takes judicial notice of the principle enunciated in Ramos v. Court of Appeals^[101] that the testimony of an expert witness is not required in cases where the doctrine of res ipsa loquitur is applicable. This Court, in Ramos, explained the rationale, thus:

Although generally, expert medical testimony is relied upon in malpractice suits to prove that a physician has done a negligent act or that he has deviated from the standard medical procedure, when the doctrine of res ipsa loquitur is availed by the plaintiff, the need for expert medical testimony is dispensed with because the injury itself provides the proof of negligence. The reason is that the general rule on the necessity of expert testimony applies only to such matters clearly within the domain of medical science, and not to matters that are within the common knowledge of mankind which may be testified to by anyone familiar with the facts. Ordinarily, only physicians and surgeons of skill and experience are competent to testify as to whether a patient has been treated or operated upon with a reasonable degree of skill and care. However, testimony as to the statements and acts of physicians and surgeons, external appearances, and manifest conditions which are observable by anyone may be given by non-expert witnesses. Hence, in cases where the res ipsa loquitur is applicable, the court is permitted to find a physician negligent upon proper proof of injury to the patient, without the aid of expert testimony, where the court from its fund of common knowledge can determine the proper standard of care. Where common knowledge and experience teach that a resulting injury would not have occurred to the patient if due care had been exercised; an inference of negligence may be drawn giving rise to an application of the doctrine of res ipsa loquitur without medical evidence, which is ordinarily required to show not only what occurred but how and why it occurred. When the doctrine is appropriate, all that the patient must do is prove a nexus between the particular act or omission complained of and the injury sustained while under the custody and management of the defendant without need to produce expert medical testimony to establish the standard of care. Resort to res ipsa loquitur is allowed because there is no other way, under usual and ordinary conditions, by which the patient can obtain redress for injury suffered by him.^[102]

This Court takes heed of the following salient portions of Dr. Malvar's testimony:

Atty. Damasen:
Q.	Doctor, since the said patient came to you, you examined her, is that correct?
A.	That is true.
Q.	And what came out after you examined her?
A.	We decided to clean the wound. I referred the patient to Dr. Cabucana for medical and enductrine (sic) clearance.
Q.	Why did you refer the patient to Dr. Cabucana De Guzman?
A.	You see, my field of specialization is surgery. I am (sic) specialist in general surgery. She is a specialist in Diabetes Melitus (sic). I referred the patient to her because she is capable and able.
Q.	Now, what did Dr. Cabucana De Guzman do after referring the patient to her?
A.	She gave orders in the chart.
Q.	And do you have these orders now?
A.	It is written in this chart.
	x x x x
Q.	Doctor, since we are layman (sic), will you please explain to this Honorable Court the layman's term, the medications that were ordered by Dr. Cabucana De Guzman?
A.	The first time that we order (sic) Insulin, it was written 8 units, every 6 hours, 6-12, 6-12 before meals, meaning to say, that the patient must be injected every 6 hours before meals.[103]
	x x x x
Atty. Damasen:
Q.	Now will you please tell us, doctor, the oral medication that would be continued? Tell us the medications that would be continued by the patient per medical check-up?
A.	This was the oral medication that we ordered. The Simbastusin, the ferrous sulfate and that's it.
Q.	Are you sure?
A.	yes, sir.
Q.	So, after that what else?
A.	There are also other orders.
Atty. Damasen: No, no, no, the post operation only.
Witness:
A.	Also, after ordering continue (sic) oral and intravenous, given Insulin as ordered, and then, we also ordered pre-medications Ketorolac that is thru intra venous (sic), mefenamic acid, that's oral medication. Then flat on bed till 9:00 p.m. There is also a word referral, that means that if something happen (sic), you refer.
Atty. Damasen:
Q.	So doctor, this is post operation instruction were made by you and was placed in the chart because that is for the safety of the patient, is that correct?
A.	Yes, sir.
Q.	And also, it is your obligation as the doctor of the patient to order these things?
A.	Yes. It is my duty.[104]
	x x x x
Q.	What was the gist of your instruction, doctor?
A.	If I may give what I have written, sir, we have wrote here that the patient should be brought to recovery room, monitored vital signs every 15 minutes for two hours then every four hours thereafter, and it was also ordered to (sic) the patient can already eat if she [is] fully awake, we have ordered to continue all the medicines has (sic) ordered and gave insulin as ordered and pay medications, sir.
Q.	To whom did you give that instruction, doctor?
A.	Sir, those instructions when we wrote a post operative order, it give (sic) to the nurses who are supposed to be stayed to the recovery room, if there is no recovery room, whoever the nurse who was going to receive the patient should do our orders at that time, sir.
Q.	Do you know?
A.	No, sir.
Q.	So you want to impress the Honorable Court that it is the nurses who are in duty or doctors who are in duty that would implement?
A.	No, sir, it should be the nurses who are on duty, not the doctor on duty.
Q.	Now, do you know, doctor, if insulin was administered to the patient?
A.	If I may refer it to the record.
	x x x x
A.	Yes, sir, according to the record, Humulin R it was given 8 units, it was given 3 times, sir.[105]
	x x x x
Q.	So you want to impress [to] the Honorable Court, doctor, that insulin was administered?
A.	Yes, sir.
Q.	And by reason of that, a patient is still alive? Can you explain to this Honorable Court why the patient died, is it through the absence of insulin or through the administration of insulin?
	x x x x
A.	I have ordered in the chart that before we give insulin, blood sugar should be requested. Now, the reason for that is that, if the insulin as mentioned by the previous attorney, if the insulin is high, it means it is justifiable to give the insulin. However, if it is normal or low, the insulin should not be given. The reason is that you are going to deplete the patient from glucose which is supposed to be the energy of the entire body from the brain down to the vital organs. Now, if you give insulin without testing the blood sugar, you are exposing the patient of a very risk of Hypoglycemia. Hypoglycemia is a very dangerous medical condition. It can render the patient incapacitated or it can even immediately kill a patient. How can be an (sic) insulin kill? The brain is very dependent with glucose, sir.
Q.	Now, do you know from the chart if a blood sugar test was conducted on the patient Teresita Baltazar?
A.	As stated on the record, the blood sugar was tested morning before the operation, insulin was not treated during that time, sir. I believe it was given at 6AM I think. It was given, so there was a blood sugar test on the initial insulin administration. So that it was justified, but the two doses of insulin that was given, there was no blood sugar test to that. It was given blindly and from there, we can see and we can follow that the condition of the patient immediately deteriorated from a normal condition crushing (sic) to death, sir.
Atty. Dirige:
Q.	From the chart, can you identify to the Honorable Court the two insulin which were administrated to the patient without any (sic) conducting blood sugar test?
A.	This was given on (sic) 11:30 and then 5:20, it was written here, sir.[106]
	x x x x
Atty. Dirige:
	Well, with the admission of the death of Teresita Baltazar, I am showing to the doctor Certificate of Death which is marked as Exhibit "A."
Q.	Now, doctor, there appears a printed name and signature above (sic) certain name, now tell the Honorable Court whose signature is that?
A.	That is my signature.
Atty. Dirige:
	May we respectfully pray that the signature of Jade Malvar be marked as Exhibit "A-1."
Q.	It appears also, doctor, that in Exhibit "A," No. 17 Metabolic Encephotopathy (sic) versus myocardial infaction (sic). What do you mean by that?
A.	I am really sure about this, sir. I did signed (sic) the Death Certificate.
Q.	Now, from No. 17, these are in order A, B, C, in layman's term or language, can you tell the Honorable Court the cause of death of said patient, doctor?
	x x x x
A.	The brain has been damaged or the heart failed to function. This diagnosis actually is intertwine (sic). Since there was no autopsy, the possible cause (sic) eventually the Insulin administration.
Q.	How about the second, Hypoglycemic versus Myocardial infaction (sic)?
A.	Almost the same underlying causes.[107]
	x x x x
Atty. Damasen:
Q.	Now in this case of Teresita Laurena Baltazar, your patient, who died, the causes of death are Metabolic Encephotopathy (sic) versus Myocardial Infarction. Meaning to say, you are not sure if this is really the cause of death of Teresita Laurean (sic) Baltazar, is that correct?
A.	Yes.
Q.	Likewise, it was stated here that the cause of death of Teresita Laurena Baltazar is Hypoglycemia versus Myocardial Infarction.
	x x x x
A.	Yes.
Q.	And again you said in the Medical Certificate, probably Hypoglycemia verses Myocardial Infarction. Why do you say probably?
A.	The doctors know that when we give Insulin, the function of Insulin is to recover the blood sugar in the blood stream (sic). The problem is so low blood sugar; the brain will stop and the muscles will stop to function.
COURT:
	Just answer the question. What do you mean when you said probably?
Witness:
A.	I am not 100% sure.
Atty. Damasen:
Q.	Now, doctor, you are now telling this Honorable Court that the cause of death of the patient is because of the fact that the hospital injected Insulin to the patient, am I correct?
A.	Not the hospital. A certain Nurse.
Atty. Damasen:
Q.	A certain nurse injected the insulin that is the cause of death?
A.	Yes.[108]

Dr. Malvar's testimony regarding petitioners' negligence also finds support in the records. It appears that prior to the operation, the nurses were charged with administering insulin, Humulin R, based on the following schedule, on the condition that an RBS test must first be conducted prior to each injection, to wit: 6:00 a.m., 12:00 noon, 6:00 p.m., and 12:00 m.n.^[109] Similarly, Teresita's post-operation treatment bore similar instructions: "give insulin as ordered."^[110] As thoroughly explained by Dr. Malvar, an RBS test is required to ascertain whether the patient would be in need of insulin to manage diabetes. Simply put, if the test results yield that blood sugar levels are normal or below normal, insulin should not be given; alternatively, if blood sugar levels appear above normal, the administration of insulin would be necessary in order to stabilize the condition of the patient. As such, it was required of De Vera, whose shift was from 8:00 a.m. to 4:00 p.m., to administer insulin at 12:00 n.n. and, thereafter, endorse such instructions to Reyno, whose shift began at 4:00 p.m. to 12:00 m.n., who must therefore administer insulin at 6:00 p.m. and at 12:00 m.n. To recall, any administration of insulin, if required, must be accompanied by a prior RBS test.

Lamentably, these instructions were not followed. Documentary evidence proves that Teresita was injected with insulin twice on different times, or at 11:30 a.m. by De Vera, and at 5:20 p.m. by Reyno.^[111] Worse, petitioners injected insulin into Teresita's system without the required RBS test.^[112] Consequently, as testified by Dr. Malvar, it would not be farfetched to conclude that such haphazard introduction of insulin twice placed Teresita at risk of contracting hypoglycemia, which most likely caused her death.

In the same vein, this Court rejects the general denial put forth by petitioners that an RBS test was, in fact, conducted.^[113] To begin with, De Vera was subjected to an investigation conducted by no less than the chief of the EDH, Dr. Ventura, which found her guilty of negligence for the improper endorsement of the physician's orders for RBS test prior to insulin injection.^[114] To make matters worse, there is no record, aside from petitioners' unsubstantiated declaration, that confirms the conduct of an RBS test prior to the insulin injections made at 11:30 a.m. and at 5:20 p.m. Aggravating is the fact that even the nurses' personal notes, which indicate the nurses' conformity to the doctors' orders, fail to corroborate petitioners' suppositions. Being experienced nurses employed at the EDH since 1989,^[115] it is not too much to expect that petitioners would duly record their compliance with the physician's orders.^[116] This practice was familiar to petitioners, as De Vera herself even noted that she had endorsed Teresita to Reyno after her shift ended.^[117] Here, it is regretful that all other orders, such as monitoring Teresita's vital signs and the administration of all oral and IV medications were recorded, all except the conduct of an RBS test.^[118] As aptly observed by the CA:

This Court painstakingly went over every page of Teresita's medical records. Records show that there was no RBS test conducted prior to the 11:30 o'clock in the morning and 5:20 o'clock in the afternoon administration of insulin. This Court finds this quite odd and very telling, considering that the other orders like the taking of vital signs every 15 minutes, and administration of oral and IV medications were complied with and duly recorded. x x x^[119]

In the final analysis, this Court finds the application of res ipsa loquitur appropriate. Through their tortious conduct, petitioners endangered the life of Teresita, in contravention to the ethical code and standards of practice held dear by those in the medical profession. To be sure, petitioners are not found to have intentionally caused Teresita's death. However, it is well to be reminded that "intent is immaterial in negligence cases because where negligence exists and is proven, the same automatically gives the injured a right to reparation for the damage caused."^[120] As Teresita's pre- and post-operation care were consigned to petitioners, who failed in this regard, this Court is hardpressed to hold them liable for damages, the amounts of which would never be commensurate to the loss suffered by respondents.

ACCORDINGLY, premises considered, the instant Petition is DENIED. The Decision dated June 28, 2016 and the Resolution dated September 20, 2016 of the Court of Appeals in CA-G.R. CV No. 105915, finding petitioners Eleanor Reyno and Elsa De Vera jointly and severally liable to pay respondents George Baltazar and Joel Baltazar the amount of P28,690.00 as actual damages, P50,000.00 as civil indemnity, P200,000.00 as moral damages, P100,000.00 as exemplary damages, and P50,000.00 as attorney's fees, are AFFIRMED.

SO ORDERED.

Leonen, SAJ. (Chairperson), Lazaro-Javier, M. Lopez, and Kho, Jr., JJ., concur.

---

^[1] Rollo, pp. 10-29.

^[2] Penned by Presiding Justice Remedios A. Salazar-Fernando, with Associate Justices Priscilla J. Baltazar-Padilla (a retired member of this Court) and Socorro B. Inting, concurring; id. at 31-57.

^[3] Id. at 59-63.

^[4] Penned by Judge Efren M. Cacatian; id. at 166-185.

^[5] Rollo, p. 32.

^[6] TSN, August 11, 2011, p. 3.

^[7] Rollo, p. 33.

^[8] TSN, August 11, 2011, p. 11.

^[9] Records, p. 258.

^[10] Id.

^[11] Id. at 261 (see dorsal portion).

^[12] TSN, June 25, 2012, p. 11.

^[13] TSN, October 3, 2012, p. 5.

^[14] Id. at 12-13.

^[15] Rollo, p. 50.

^[16] TSN, August 11, 2011, pp. 19-20.

^[17] TSN, May 3, 2012, p. 9.

^[18] Rollo, p. 50.

^[19] Id. at 33.

^[20] TSN, October 3, 2012, p. 12.

^[21] Rollo, p. 33.

^[22] TSN, October 3, 2012, p. 16.

^[23] Id. at 19.

^[24] Id. at 21.

^[25] Id.

^[26] Rollo, p. 33.

^[27] See Amended Complaint dated July 7, 2010, rollo, pp. 104-112.

^[28] Id. at 166-185.

^[29] Id. at 185.

^[30] Id. at 181.

^[31] Id. at 183-184.

^[32] Id. at 184.

^[33] Id.

^[34] Id. at 185.

^[35] Id.

^[36] See Motion for Reconsideration dated June 26, 2015, records, pp. 519-522.

^[37] Id. at 534.

^[38] See Notice of Appeal dated August 10, 2015; id. at 535-536.

^[39] Rollo, pp. 31-57.

^[40] Id. at 56.

^[41] Id. at 44.

^[42] Id. at 45.

^[43] Id. at 46.

^[44] Id. at 50.

^[45] Id. at 264-275.

^[46] Id. at 269.

^[47] Id. at 59-63.

^[48] 514 Phil. 166, 167 (2005).

^[49] Rollo, p. 62.

^[50] Id. at 21-22.

^[51] Id. at 22.

^[52] Id. at 307-316.

^[53] Id. at 310.

^[54] Id. at 312.

^[55] Id. at 312-313.

^[56] Id. at 331-339.

^[57] Id. at 336.

^[58] Id. at 11-12.

^[59] People v. Juan, 379 Phil. 125, 138-139 (2000).

^[60] Supra note 48.

^[61] Id. at 174-175. (Emphases supplied; citations omitted)

^[62] 635 Phil. 598 (2010).

^[63] Id. at 604.

^[64] 738 Phil. 71 (2014).

^[65] 710 Phil. 549 (2013).

^[66] Id. at 557.

^[67] Records, pp. 22-23.

^[68] Id. at 33-39.

^[69] Rollo, p. 62. (Citation omitted)

^[70] City of Dagupan v. Maramba, supra note 64, at 89.

^[71] G.R. No. 243900, October 6, 2021.

^[72] Id.

^[73] A.M. No. 19-10-20-SC, entitled "Proposed Amendments to the 1997 Rules of Civil Procedure," effective May 1, 2020.

^[74] Oxales v. United Laboratories, Inc., 581 Phil. 23, 38 (2008).

^[75] 34 U.S. 378 (1835).

^[76] 3 H. &. C. 596 (1865).

^[77] Id. at 601.

^[78] 123 Phil. 272 (1966).

^[79] C.A. G.R. No. L-3240-R, September 20, 1949.

^[80] Supra note 78, at 279-280. (Emphasis and underscoring supplied)

^[81] Ramos v. Court of Appeals, 378 Phil. 1198, 1220 (1999).

^[82] Malayan Insurance Co., Inc. v. Alberto, et al., 680 Phil. 813,827 (2012).

^[83] Interphil Laboratories, Inc. v. OEP Philippines, Inc., G.R. No. 203697, March 20, 2019, 897 SCRA 497, 517.

^[84] Capili v. Spouses Cardaña, 531 Phil. 60, 67 (2006).

^[85] Supra note 81.

^[86] 434 P.2d 160, 166 (1967).

^[87] Ramos v. Court of Appeals, supra note 81.

^[88] Id. at 1221.

^[89] Id. at 1222.

^[90] Reyes v. Sisters of Mercy Hospital, 396 Phil. 87, 95-96 (2000).

^[91] Dr. Cantre v. Spouses Go, 550 Phil. 637 (2007).

^[92] Ramos v. Court of Appeals, supra note 81.

^[93] Dr. Batiquin v. Court of Appeals, 327 Phil. 965 (1996).

^[94] Rosit v. Davao Doctors Hospital, et al., 774 Phil. 393 (2015).

^[95] TSN, May 3, 2012, p. 8.

^[96] Rollo, p. 45.

^[97] TSN, May 3, 2012, p. 3.

^[98] Ramos v. Court of Appeals, supra note 81, at 1223.

^[99] Rollo, p. 74.

^[100] 398 Phil. 559, 567 (2000).

^[101] Supra note 81.

^[102] Id. at 1221-1222. (Emphases supplied; citations omitted)

^[103] TSN, August 11, 2011, p. 11. (Emphasis supplied)

^[104] Id. at 24-25. (Emphases supplied)

^[105] TSN, September 8, 2011, p. 15.

^[106] TSN, September 8, 2011, pp. 16-18. (Emphases supplied)

^[107] TSN, August 11, 2011, pp. 8-9.

^[108] Id. at 26-27. (Emphasis supplied)

^[109] Records, p. 258.

^[110] Id. (dorsal portion).

^[111] Id. at 256 (dorsal portion); see CA Decision dated June 28, 2016, rollo, p. 50.

^[112] Id.

^[113] Rollo, p. 47.

^[114] See Memorandum Order No. 012, Series of 2009; records, p. 234.

^[115] See Service records; id. at 466-467.

^[116] See Nurses' Notes; id. at 260-262.

^[117] TSN, May 3, 2012, p. 9.

^[118] Rollo, p. 47.

^[119] Id. (Citation omitted)

^[120] Ramos v. Court of Appeals, supra note 81, at 1247.