forensic medicine

Forensic Medicine for Atty. Patdu by Jason Arteche

Feel free to use and share this digest with anyone who needs it Don’t ask me anymore, I’ll just say Yes J

1

Physician-Patient privilege The law in point is paragraph (c), Section 24 of the Revised Rules on Evidence that reads: SECTION 24. Disqualification by reason of privileged communication. — The following persons cannot testify as to matters learned in confidence in the following cases:

xxx (c) A person authorized to practice medicine, surgery or obstetrics cannot in a civil case, without the consent of the patient, be examined as to any advice or treatment given by him or any information which he may have acquired in attending such patient in a professional capacity, which information was necessary to enable him to act in that capacity, and which would blacken the reputation of the patient.

The object of the privilege is to protect the patient; it may be waived if no timely objection is made to the physician’s testimony. In order that the privilege may be successfully claimed, the following requisites must concur:

1. The privilege is claimed in a civil case; 2. The person against whom the privilege is claimed is one duly authorized to practice medicine,

surgery or obstetrics; 3. Such person acquired the information while he was attending to the patient in his professional

capacity; 4. The information was necessary to enable him to act in that capacity; and 5. The information was confidential, and, if disclosed, would blacken the reputation (formerly

character) of the patient.

These requisites conform to the four (4) fundamental conditions necessary for the establishment of a privilege against the disclosure of certain communications, to wit:

1. The communications must originate in a confidence that they will not be disclosed. 2. This element of confidentiality must be essential to the full and satisfactory maintenance of

the relation between the parties. 3. The relation must be one that in the opinion of the community ought to be sedulously fostered 4. The injury that would inure to the relation by the disclosure of the communications must be

greater than the benefit thereby gained for the correct disposal of litigation."

The physician may be considered to be acting in his professional capacity when he attends to the patient for curative, preventive, or palliative treatment. Thus, only disclosures which would have been made to the physician to enable him "safely and efficaciously to treat his patient" are covered by the privilege. It is to be emphasized, "It is the tenor only of the communication that is privileged. The mere fact of making a communication, as well as the date of a consultation and the number of consultations, are therefore not privileged from disclosure, so long as the subject communicated is not stated." One who claims this privilege must prove the presence of these aforementioned requisites.



2

Lim vs CA Facts Petitioner and private respondent are lawfully married to each other. Private respondent filed with the Regional Trial Court (RTC) a petition for annulment of marriage on the ground that petitioner has been allegedly suffering from a mental illness called schizophrenia "before, during and after the marriage and until the present." Private respondent’s counsel announced that he would present as his next witness the Chief of the Female Services of the National Mental Hospital, Dr. Lydia Acampado, a Doctor of Medicine who specializes in Psychiatry. Said counsel forthwith orally applied for the issuance of a subpoena ad testificandum requiring Dr. Acampado to testify. Petitioner’s counsel opposed the motion on the ground that the testimony sought to be elicited from the witness is privileged since the latter had examined the petitioner in a professional capacity and had diagnosed her to be suffering from schizophrenia. Issue Whether or not Dr. Acampado’s testimony falls under the physician-patient privilege. Held The testimony doesn’t fall under the privilege. In the first place, Dr. Acampado was presented and qualified as an expert witness. Otherwise stated, her expert opinion excluded whatever information or knowledge she had about the petitioner that was acquired by reason of the physician-patient relationship existing between them. As an expert witness, her testimony before the trial court cannot then be excluded. Secondly, it is quite clear from Dr. Acampado’s testimony that the petitioner was never interviewed alone. Said interviews were always conducted in the presence of a third party. There is authority to the effect that information elicited during consultation with a physician in the presence of third parties removes such information from the mantle of the privilege. Thirdly, except for the petitioner’s sweeping claim — that" (T)he information given by Dr. Acampado brings disgrace and invite (sic) reproach to petitioner by falsely making it appear in the eyes of the trial court and the public that the latter was suffering from a mental disturbance called schizophrenia — which caused, and continues to cause, irreparable injury to the name and reputation of petitioner and her family," — which is based on a wrong premise, nothing specific or concrete was offered to show that indeed, the information obtained from Dr. Acampado would blacken the former’s "character" (or "reputation"). Finally, while it may be true that counsel for the petitioner opposed the oral request for the issuance of a subpoena ad testificandum to Dr. Acampado and filed a formal motion for the quashal of the said subpoena a day before the witness was to testify, the petitioner makes no claim in any of her pleadings that her counsel had objected to any question asked of the witness on the ground that it elicited an answer that would violate the privilege, despite the trial court’s advise that said counsel may interpose his objection to the testimony "once it becomes apparent that the testimony, sought to be elicited is covered by the privileged communication rule." The particular portions of the stenographic notes of the testimony of Dr. Acampado quoted in the petitioner’s Petition and Memorandum, and in the private respondent’s Memorandum, do not at all show that any objections were interposed. Even granting ex gratia that the testimony of Dr. Acampado could be covered by the privilege, the failure to seasonably object thereto amounted to a waiver thereof.



3

Cruz vs CA Facts Rowena’s mother, Lydia, went to Lim’s clinic for a hysterectomy operation to be done by Lim. Rowena noticed the clinic was dirty and asked Lim if the operation could be postponed. Lim refused saying the operation must go on as scheduled. The operation was started and a few hours later Lim asked Rowena to go out and buy Tagamet ampules. Later, Lim again asked Rowena to buy blood, then later a supply of oxygen. After the operation, Lydia went into shock and Lim ordered her transfer to San Pablo Hospital without Rowena’s consent. At the hospital, the doctors operated on Lydia but the latter died nevertheless. Her death certificate states ‘shock’ and ‘Disseminated Intravascular Coagulation’ as causes. Rowena then filed a criminal case for reckless imprudence resulting in homicide against Lim. Issue Whether or not Lim is guilty of reckless imprudence resulting in homicide. Held Lim isn't guilty. If a physician has committed an inexcusable lack of precaution in treating his patient is determined according to the 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 or medical science at the time of treatment. Expert testimony is essential to establish both the profession’s standard of care and the physician’s conduct falls below that standard. In this case, there were no expert testimonies on the standard of care employed by other physicians of good standing in conducting similar operations. The expert witnesses actually presented only testified as to the cause of death. Further, no expert witness was offered to prove the dirty clinic and insufficient provisions constitute falling below the standard of care employed by other physicians in good standing. Also, no proof exists that these circumstances caused Lydia’s death. There must be a causal connection of negligence/breach and the patient’s resulting death.



4

Cayatao-Lasam vs Ramolete Facts Ramolete is 3-months pregnant and was admitted to Lorma Medical Center due to vaginal bleeding. Cayatao-Lasam advised Ramolete to undergo a Dilatation and Curettage Procedure (D&C) due to profuse vaginal bleeding. Cayatao-Lasam performed the operation and Ramolete was discharged from the hospital the next day. However, a few weeks later Ramolete was brought back to Lorma Medical due to vomiting and severe abdominal pains. The doctors at Lorma Medical Center informed Ramolete she had a dead fetus in her womb. The doctors performed a hysterectomy operation on her and as a result she could no longer bear a child. Ramolete filed a case for gross negligence and malpractice against Cayatao-Lasam before the PRC. The PRC revoked Cayatao-Lasam’s license causing him to appeal the PRC decision to the regular courts. Issue Whether or not Cayatao-Lasam is guilty of medical malpractice. Held Cayatao-Lasam isn't guilty. Medical malpractice is a particular form of negligence which consists in a physician failing to apply to his practice the degree of skill and care ordinarily employed by the profession generally under similar conditions and circumstances. Such failure on the physician’s part must have caused the patient’s injury. Expert testimony is essential to prove malpractice. Medical negligence has 4 elements namely:

1. Duty, 2. Breach, 3. Injury, 4. Proximate causation.

In this case, no expert witness was presented to support the claim that Cayatao-Lasam was negligent in his practice. On the other hand, Cayatao-Lasam presented an expert witness, Dr. Manalo, who testified the D&C procedure wasn’t the proximate cause of the rupture of Ramolete’s uterus resulting in her hysterectomy. Further, Dr. Manalo testified the D&C procedure was conducted in accordance with profession’s standard practice. Also, Ramolete herself was negligent leading to her own injury. Cayatao-Lasam advised Ramolete to return after the operation for a follow-up evaluation. If only Ramolete did as she was told, Cayatao-Lasam could’ve determined her health condition and applied the corresponding treatment thereby preventing the rupture of Ramolete’s uterus. Consequently, Ramolete’s negligence was the immediate cause of her own injury.



5

Layugan vs Intermediate Appelate Court Facts Respondent Isidro and his driver Serrano was driving a truck along the road when they bumped Layugan. At the time, Layugan was repairing his cargo truck parked along the right side of the road. As a result, Layugan was injured and hospitalized. Layugan filed an action for damages. Isidro argued Layugan’s failure to install an early warning device caused the incident because Layugan’s truck was parked right after the curve of the road. Issue Whether or not Layugan is negligent under the doctrine of Res ipsa loquitur. Held Layugan isn't negligent. Negligence is the omission to do something that an ordinarily prudent person would’ve done in the same situation. Meanwhile, the doctrine of res ipsa loquitur states ‘Where the thing which causes injury is shown to be under the defendant’s management, and the accident is such as in the ordinary course of things doesn’t happen if those who have management use the proper care, it affords reasonable evidence, in the absence of an explanation from the defendant the accident arose from want of care. The doctrine of res ipsa loquitur merely determines and regulates what shall be prima facie evidence of negligence and facilitates plaintiff’s burden of proving a breach of the duty of due care. This doctrine can be invoked only when direct evidence is absent and not readily available. Once the actual cause of injury is established beyond controversy, no presumptions will be involved and the doctrine is inapplicable. In this case, the evidence shows Layugan actually placed a lighted kerosene lamp a few meters from the parked truck’s rear. Despite such warning, Serrano still bumped the parked truck and Layugan. Further, before driving Serrano failed to inspect the truck and discover the malfunctioning brakes because a fluid pipe was cut. Serrano’s absence or want of care has been established by clear and convincing evidence and the doctrine of res ipsa loquitur can’t be invoked.



6

Ramos vs CA Facts Ramos was advised to undergo an operation to remove a stone in her gall bladder. She was referred to Dr. Hosaka, a surgeon, who agreed to perform the operation at De Los Santos Medical Center. The operation was scheduled and Dr Hosaka recommended Dr. Gutierrez as anesthesiologist. On the day of the operation, Dr. Hosaka arrived 3 hours late. When he did arrive, Dr. Gutierrez proceeded to intubate Ramos but something went wrong. Ramos started having a bluish discoloration on the nail beds in her left hand. Another doctor, Calderon, was brought in to intubate Ramos but the nail beds remained bluish. Afterwards, Ramos was wheeled to the ICU where she stayed for a month. Ramos was released 4 months later but since the operation she remained comatose until she died. The husband filed a civil case for damages against the hospital and doctors involved in the operation. Issue Whether or not the hospital, Dr. Hosaka, and Dr. Gutierrez are liable for damages. Held Hospital: No. Dr. Hosaka: Yes. Dr. Gutierrez: Yes. Dr. Gutierrez failed to exercise the standards of care in administering anesthesia on a patient. She failed to conduct a preanesthetic evaluation prior to the operation, which was indispensable. Had Dr. Gutierrez performed the evaluation, she wouldn’t have experienced difficulty intubating Ramos and the resulting injury could’ve been avoided. Such faulty intubation caused the comatose condition in Ramos. Further, there’s no evidence the comatose was caused by an allergic reaction Ramos had with penthol. The comatose condition resulting from anesthesia isn’t something that ordinarily happens if due care was exercised. Considering Dr. Gutierrez performed the anesthesia, the doctrine of res ipsa loquitur rightfully applies. Dr. Hosaka is liable under the Captain-of-the-Ship doctrine. Dr. Hosaka exercised a certain degree of supervision over the procedure performed on Ramos. It was Dr. Hosaka who recommended the services of Dr. Gutierrez and it was conceded both of them worked as a team. As a team, their duties intersected with each other with one helping the other. Further, Dr. Hosaka was Ramos’ attending physician during the procedure. Also, Dr. Hosaka’s 3-hour lateness caused further anxiety to Ramos adversely affecting the administration of anesthesia on her. De Los Santos Medical Center isn’t liable because (1) there’s no employer-employee relationship between the doctors and the hospital (2) there’s no showing DLSMC failed to provide the necessary hospital facilities and staff necessary for the operation.



7

Li vs. Soliman Facts Soliman's daughter, Angelica, underwent a biopsy at St. Lukes Medical Center and discovered she had bone cancer. As a preventive measure, Dr. Tamayo amputated Angelica's leg and advised chemotherapy to contain the disease. Dr. Tamayo referred Angelica to Dr. Li, a medical oncologist to perform the chemotherapy. Angelica was admitted again to St. Lukes but died just 11 days after the first cycle of chemotherapy. St. Lukes refused to release the death certificate until the Solimans have paid in full their bill. Consequently, the Solimans brought Angelica's body to the PNP for a post-mortem examination. The PNP examination stated the cause of death was 'Hypovolemic shock secondary to multiple organ hemorrhages and Disseminated Intravascular Coagulation.' The St. Lukes death certificate states the cause of death was: Immediate cause: a. Osteosarcoma, Status Post AKA Antecedent cause: b. (above knee amputation) Underlying cause: c. Status Post Chemotherapy The Solimans then filed a case against St. Lukes Medical and the doctors involved in the chemotherapy alleging negligence and disregard of Angelica's health in administering the chemotherapy. The careless administration of chemotherapy led to bleeding which led to shock causing Angelica's death. In the lower courts, Li's negligence wasn't proven but Li was still convicted because of failure to state all the possible side effects of chemotherapy to the Solimans before they gave their consent. Issue Whether or not Li can be held liable for failing to disclose all the possible side effects of chemotherapy to the parents of the child parent despite the absence of negligence on Li's part in administering the chemotherapy. Held Li can't be held liable. There are four essential elements a plaintiff must prove in a malpractice action based upon the doctrine of informed consent:

1. The physician had a duty to disclose material risks; 2. He failed to disclose or inadequately disclosed those risks; 3. As a direct and proximate result of the failure to disclose, the patient consented to treatment

she otherwise would not have consented to; and 4. Plaintiff was injured by 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. In this case, there was adequate disclosure on Li's part on the possible side effects of chemotherapy.



8

Nogales vs. Capitol Medical Center Doctrine …Likewise unconvincing is CMC's argument that petitioners are estopped from claiming damages based on the Consent on Admission and Consent to Operation. Both release forms consist of two parts. The first part gave CMC permission to administer to Corazon any form of recognized medical treatment which the CMC medical staff deemed advisable. The second part of the documents, which may properly be described as the releasing part, releases CMC and its employees "from any and all claims" arising from or by reason of the treatment and operation. The documents do not expressly release CMC from liability for injury to Corazon due to negligence during her treatment or operation. Neither do the consent forms expressly exempt CMC from liability for Corazon's death due to negligence during such treatment or operation. Such release forms, being in the nature of contracts of adhesion, are construed strictly against hospitals. Besides, a blanket release in favor of hospitals "from any and all claims," which includes claims due to bad faith or gross negligence, would be contrary to public policy and thus void. Even simple negligence is not subject to blanket release in favor of establishments like hospitals but may only mitigate liability depending on the circumstances. When a person needing urgent medical attention rushes to a hospital, he cannot bargain on equal footing with the hospital on the terms of admission and operation. Such a person is literally at the mercy of the hospital. There can be no clearer example of a contract of adhesion than one arising from such a dire situation. Thus, the release forms of CMC cannot relieve CMC from liability for the negligent medical treatment of Corazon.



9

Professional Services Inc. vs CA Facts Agana went to Medical City because of pain in her anal region. Dr. Ampil diagnosed her with cancer and recommended surgery. Dr. Ampil then, with assistance from Medical City staff, performed surgery. During surgery, a hysterectomy operation was required. Dr. Fuentes performed the hysterectomy after which Ampil took over and finished surgery. After a few days Agana experienced excruciating pain in her anal region. She consulted Ampil and Fuentes but both of them assured her that was a natural consequence of surgery. Both doctors advised her to seek further treatment to completely remove the cancer. Agana then went to the US to completely remove the cancer. Later, Agana returned to the Philippines still experiencing pain when it was discovered she had a gauze protruding from her vagina. Agana then went to Polymedic General where Dr. Gutierrez discovered more gauzes in her vagina. Another surgery was performed to remove the gauzes. Agana then filed suit before the RTC against PSI (Medical City's owner), Ampil, and Fuentes. Issue Whether or not Medical City is liable for Dr. Ampil's negligence. Held Medical City is liable. Hospitals exercise significant control in the hiring and firing of consultants and supervision over work conducted within its premises. An accepted physician has certain responsibilities to the hospital such as:

1. Attending conferences 2. Conducting bedside rounds 3. Auditing patients 4. And other tasks and responsibilities.

Further, a peer-review committee generally evaluates physicians and a physician who is remiss in his duties or regularly falls short of the committee's standards is terminated. Granting, physicians aren't technically hospital employees, the control exercised, hiring, and right to terminate physicians all fulfill the important hallmarks of an employer-employee relationship. Accordingly, for the purpose of allocating responsibility in medical negligence cases, an employer-employee relationship in effect exists between hospitals and their hired physicians. The doctrine of apparent authority also applies in this case because Medical City made it appear to the public that Dr. Ampil was a member of its hospital staff. There's no need for it to make an express representation to the patient that the treating physician is a hospital employee, such representation may be general and implied. Simply displaying his name in the lobby's public directory is enough. The doctrine of corporate responsibility gives hospitals the responsibility to properly supervise its medical staff. A hospital has the duty to make a reasonable effort to monitor and oversee work its hired physicians' perform. In this case, Medical City was remiss in its duty because it didn't conduct an immediate investigation on the reported missing gauzes to Agana's prejudice. The testimony from a doctor of Medical City's medical staff showed lack of concern for the patients and reflects the hospital's manner of supervision. Consequently, Medical City is both vicariously liable for Ampil's negligence under an employer-employee relationship and directly liable for its own negligence in failing to conduct an immediate investigation on the missing gauzes.



10

Professional Services Inc. vs CA Facts see above Issue Whether or not Medical City is liable for Dr. Ampil's negligence. Held Medical City is liable. In this case, Medical City is liable to Agana not under the principle of respondeat superior for insufficient evidence of an employer-employee relationship with Dr. Ampil. But under the principle of ostensible agency for Ampil's negligence and corporate negligence in failing to perform its duties as a hospital. Here, there was insufficient evidence to show Medical City exercised the power of control or wielded such power over the means and details over the specific operation Dr. Ampil performed on Agana. However, there's evidence Medical City held out Dr. Ampil to Agana as its agent. The 2 factors determining apparent authority are present namely:

1. Hospital manifestation and 2. Patient’s reliance.

Hospital manifestation refers to the hospital’s conduct that led the patient to conclude the physician was the hospital’s agent. Meanwhile, patient’s reliance refers to such reliance upon the hospital and doctor’s conduct consistent with ordinary care and prudence. Agana chose Medical City on the impression Dr. Ampil was a staff member of said hospital and it was known and prominent. Further, Medical City required Agana to sign hospital documents that reinforce the idea Ampil was a physician of its hospital. The documents stipulated 'as may be deemed necessary or advisable by the hospital's physicians'. Further, Medical City itself admitted it had the power to review Dr. Ampil's operation and the irregularity of the missing gauzes. The purpose of such review would've been to inform Agana of what transpired during surgery and find out what happened to the missing gauzes. The surgery's medical records showing the missing gauzes should've been enough for Medical City to initiate a review. However, it failed to perform such review and instead delegated the responsibility to Ampil hoping the latter would fix the problem and find the gauzes. Simply put, it shirked its responsibility to review Dr. Ampil's operation. Consequently, Medical City is liable under the doctrine of corporate negligence in failing to perform its duties as a hospital, and ostensible agency for Dr. Ampil’s negligence.

forensic medicine

Documents