G.R. No. 163879 & 165805 July 30, 2014

Ten (10)-year old Rodolfo F. Palma, Jr. (JR) complained of abdominal pain to his mother, Rosario Palma. At 5 o’clock that samea fternoon, Palma’s mother and father, Atty. Rodolfo Palma Sr., brought JR to the clinic of accused Dr. Cabugao. Dr. Cabugao, a general practitioner, specializing in family medicine gave medicines for the pain and told Palma’s parents to call him up if his stomach pains continue. Due to persistent abdominal pains, they returnedto Dr. Cabugao, who advised them to bring JR to the Nazareth General Hospital in Dagupan City, for confinement. JR was admitted at the said hospital at 5:30 in the morning. Dr. Cabugao did a rectal examination, the initial impression was Acute Appendicitis, and hence, he referred the case to his co-accused, Dr. Ynzon, a surgeon. Dr. Ynzon went to the hospital and read the CBC and ultrasound results. The administration of massive antibiotics and pain reliever to JR were ordered. Thereafter, JR was placed on observation for twenty-four (24) hours. JR complained again of abdominal pain and his parents noticed a swelling in his scrotum. In the afternoon of the same day, JR vomitted out greenish stuff three (3) times and had watery bowels also three (3) times. The nurses on-duty relayed JR’s condition to Dr. Ynzon who merely gave orders via telephone.9Accused continued medications to alleviate JR’s abdominal spasms and diarrhea. By midnight, JR again vomitted twice, had loose bowel movements and was unable to sleep. The following morning, JR’s condition worsened, he had a running fever of 38°C. JR’s fever remained uncontrolled and he became unconscious, he was given Aeknil (1 ampule) and Valium (1 ampule). JR’s condition continued to deteriorate that by 2 o’clock in the afternoon, JR’s temperature soared to 42°C, had convulsions and finally died. The Death Certificate dated June 19, 2000 prepared by Dr. Cabugao indicated the following causes of death: Immediate cause: CARDIORESPIRATORY ARREST An Information was filed against accused for reckless imprudence resulting to homicide. At their arraignment, both accused, duly assisted by counsel, pleaded not guilty to the charge.

Negligent in the performance of their duties:
1. 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.

2. 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

3. There may have been other diseases but the records do not show that the accused took steps to find outwhat 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

Whether or not petitioners’ conviction of the crime of reckless imprudence resulting in homicide, arising from an alleged medical malpractice, is supported by the evidence on record.

Reckless imprudence consists of voluntarily doing or failing to do, without malice, an act from which material damage results by reason of an inexcusable lack of precaution on the part of the person performing or failing to perform such act. The elements of reckless imprudence are: (1) that the offender does or fails to do an act; (2) that the doing or the failure to do that act is voluntary; (3) that it bewithout malice; (4) that material damage results from the reckless imprudence; and (5) that there is inexcusable lack of precaution on the part of the offender, taking into consideration his employment or occupation, degree of intelligence, physical condition, and other circumstances regarding persons, time and place.14

With respect to Dr. Ynzon, all the requisites of the offense have been clearly established by the evidence on record. The court a quoand the appellate court were one in concluding that Dr. Ynzon failed to observe the required standard of care expected from doctors.

In the instant case, it was sufficiently established that to prevent certain death, it was necessary to perform surgery on JR immediately. Even the prosecution’s own expert witness, Dr. Antonio Mateo. From the witness examination, it is clear that if JR’s condition remained unchecked it would ultimately result in his death, as what actually happened in the present case. Another expert witness for the defense, Dr. Vivencio Villaflor, Jr. testified on direct examination that he would perform a personal and thorough physical examination of the patient as frequent as every 4 to 6 hours.
From the testimonies of the expert witnesses presented, it was irrefutably proven that Dr. Ynzon failed to practice that degree of skill and care required in the treatment of his patient.

As correctly observed by the appellate court, Dr. Ynzon revealed want of reasonable skill and care in attending to the needs of JR by neglecting to monitor effectively the developments and changes on JR’s condition during the observation period, and to act upon the situation after the 24-hour period when his abdominal pain persisted and his condition worsened.

Lamentable, Dr. Ynzon appeared to have visited JRbriefly only during regular rounds in the mornings. He was not there during the crucial times on June 16, 2000 when JR’s condition started to deteriorate until JR’s death. As the attending surgeon, he should be primarily responsible in monitoring the condition of JR, as he is in the best position considering his skills and experience to know if the patient’s condition had deteriorated. Indeed, it is reckless and gross negligence of duty to relegate his personal responsibility to observe the condition of the patient. Again, acute appendicitis was the working diagnosis, and with the emergence of graver symptoms after the 24-hour observation, Dr. Ynzon ruled out surgery for no apparent reason.
Among the elements constitutive of reckless imprudence, what perhaps is most central to a finding of guilt is the conclusive determination that the accused has exhibited, by his voluntary act without malice, an inexcusable lack of precaution.

It is that which supplies the criminal intent so indispensable as to bring an act of mere negligence and imprudence under the operation of the penal law. This is because a conscious indifference to the consequences of the conduct is all that is required from the standpoint of the frame of mind of the accused.24 Quasi offenses penalize the mental attitude or condition behind the act, the dangerous recklessness, the lack of care or foresight, the “imprudencia punible,” unlike willful offenses which punish the intentional criminal act.25 This is precisely where this Court found Dr. Ynzon to be guilty of – his seemingly indifference to the deteriorating condition of JR that he as a consequence, failed to exercise lack of precaution which eventually led to JR’s death.

To be sure, whether or not a physician has committed an “inexcusable lack of precaution” in the treatment of his patient is to be 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 at the time of treatment or the present state of medical science.
In accepting a case, a doctor in effect represents that, having the needed training and skill possessed by physicians and surgeons practicing in the same field, he will employ such training, care and skill in the treatment of his patients. He, therefore, has a duty to use at least the same level of care that any other reasonably competent doctor would use to treat a condition under the same circumstances. Sadly, Dr. Ynzon did not display that degree of care and precaution demanded by the circumstances.

Every criminal conviction requires of the prosecution to prove two things — the fact of the crime, i.e., the presence of all the elements of the crime for which the accused stands charged, and the fact that the accused is the perpetrator of the crime. Based on the above disquisitions, however, the prosecution failed to prove these two things. The Court is not convinced with moral certainty that Dr. Cabugao is guilty of reckless imprudence as the elements thereof were not proven by the prosecution beyond a reasonable doubt.

Neither the shown evidence that Dr. Cabugao has been negligent or lacked the necessary precaution in his performance of his duty as a family doctor. On the contrary, a perusal of the medical records would show that during the 24-hour monitoring on JR, it was Dr. Cabugao who frequently made orders on the administration of antibiotics and pain relievers. There was also repetitive instructions from Dr. Cabugao to refer JR to Dr. Ynzon as it appeared that he is suspecting appendicitis. The referral of JR to Dr. Ynzon, a surgeon, is actually an exercise of precaution as he knew that appendicitis is not within his scope of expertise. This clearly showed that he employed the best of his knowledge and skill in attending to JR’s condition, even after the referral of JR to Dr. Ynzon. To be sure, the calculated assessment of Dr. Cabugao to refer JRto a surgeon who has sufficient training and experience to handle JR’s case belies the finding that he displayed inexcusable lack of precaution in handling his patient.

Moreover, while both appeared to be the attending physicians of JR during his hospital confinement, it cannot be said that the finding of guilt on Dr. Ynzon necessitates the same finding on the co-accused Dr. Cabugao. Conspiracy is inconsistent with the idea of a felony committed by means of culpa.32 Thus, the accused-doctors to be found guilty of reckless imprudence resulting in homicide, it must be shown that both accused-doctors demonstrated an act executed without malice or criminal intent – but with lack of foresight, carelessness, or negligence. Noteworthy, the evidence on record clearly points to the reckless imprudence of Dr. Ynzon; however, the same cannot be said in Dr. Cabugao’s case.


Maui Polangcos

One thought on “DR. ANTONIO P. CABUGAO vs. PEOPLE OF THE PHILIPPINES G.R. No. 163879, July 30, 2014 DR. CLENIO YNZON vs. PEOPLE OF THE PHILIPPINES G.R. No. 165805, July 30, 2014

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