G.R. No.

163879               July 30, 2014 Arising from the same events, the Court resolved to
consolidate these cases.4 The facts, as culled from the records,
DR. ANTONIO P. CABUGAO, Petitioner, are as follows:
vs.
PEOPLE OF THE PHILIPPINES and SPOUSES On June 14, 2000, at around 4 o'clock in the afternoon, ten
RODOLFO M. PALMA and ROSARIO F. (10)-year old Rodolfo F. Palma, Jr. (JR) complained of
PALMA, Respondents. abdominal pain to his mother, Rosario Palma. At 5 o’clock
that sameafternoon, Palma's mother and father, Atty. Rodolfo
x-----------------------x Palma Sr., brought JR to the clinic of accused Dr. Cabugao.
G.R. No. 165805 Dr. Cabugao, a general practitioner, specializing in
familymedicine gave medicines for the pain and told Palma's
DR. CLENIO YNZON, Petitioner, parents to call him up if his stomach pains continue. Due to
vs. persistent abdominal pains, at 4:30 in the early morning of
PEOPLE OF THE PHILIPPINES and SPOUSES June 15, 2000, they returnedto Dr. Cabugao, who advised
RODOLFO M. PALMA AND ROSARIO F. them to bring JR to the Nazareth General Hospital in Dagupan
PALMA, Respondents. City, for confinement. JR was admitted at the said hospital at
5:30 in the morning.5
DECISION
Blood samples were taken from JR for laboratory testing. The
PERALTA, J.:
complete blood count conveyed the following result: wbc –
Before this Court are appeals via Rule 45 from the 27.80 x 10 9/L; lymphocytes – 0.10 and neutrophils – 0.90.
Decision1 dated June 4, 2004 of the Court of Appeals in CA- Diagnostic ultrasound was likewise conducted on the patient's
G.R. CR No. 27293, affirming the Decision2 dated February lower abdomen by radiologist, Dr. Ricky V. Querubin, with
28,2003 of the Regional Trial Court (RTC), convicting the following findings:
appellant Dr. Antonio P. Cabugao (Dr. Cabugao) and Dr.
Normal liver, bile ducts, gallbladder, pancreas, spleen,
Clenio Ynzon (Dr. Ynzon) of the crime of Reckless
kidneys and urinary bladder.
Imprudence Resulting to Homicide.
There is no free peritoneal fluid.
The Information3 alleged –
There is localized tenderness in the paraumbilical region,
That on or about June 17, 2000in the City of Dagupan,
more so in the supra and right paraumbilical areas.
Philippines, and within the jurisdiction of this Honorable
Court, the abovenamed accused, DR. ANTONIO There is a vague elongated hypoechoic focus in the right
P.CABUGAO and DR. CLENIO YNZON, being then the periumbilical region roughly about 47 x 18 mm surrounded by
attending physicians of one RODOLFO PALMA, JR., a minor undistended gas-filled bowels. This is suggestive of an
10 years old, confederating and acting jointly with one inflammatory process wherein appendiceal or periappendiceal
another, did, then and there, willfully, unlawfully and pathology cannot be excluded. Clinical correlation is
feloniously fail through negligence, carelessness and essential."6
imprudence to perform immediate operation upon their
patient, RODOLFO PALMA, JR. of acute appendicitis, when Dr. Cabugao did a rectal examination noting the following:
they, the said physicians, should have been done so "rectal: good sphincter, negative tenderness, negative mass."
considering that examinations conducted upon their patient The initial impression was Acute Appendicitis,7 and hence, he
Rodolfo Palma, Jr. seriously manifest todo so, causing by such referred the case to his co-accused, Dr. Ynzon, a surgeon.8 In
negligence, carelessness, and imprudence the victim, the later part of the morning of June 15, 2000, Dr. Ynzon went
RODOLFO PALMA JR., to die due to: to the hospital and readthe CBC and ultrasound results. The
administration of massive antibiotics and pain reliever to
"CARDIORESPIRATORY ARREST, METABOLIC JRwere ordered. Thereafter, JR was placed on observation for
ENCEPHALOPATHY, SEPTICEMIA (ACUTE twenty-four (24) hours.
APPENDICITIS), CEREBRAL ANEURYSM RUPTURED
(?)" In the morning of June 16, 2000, JR complained again of
abdominal pain and his parents noticeda swelling in his
As per Certificate of Death issued by accused Dr. Antonio P. scrotum. In the afternoon of the same day, JR vomitted out
Cabugao, to the damage and prejudice of the legal heirs of greenish stuff three (3) times and had watery bowels also three
said deceased RODOLFO PALMA, JR. and other (3) times. The nurses on-duty relayed JR's condition to Dr.
consequential damages relative thereto. Ynzon who merely gaveorders via telephone.9 Accused
continued medications to alleviate JR's abdominal spasms and
CONTRARY to Article 365, 1st par. of the Revised Penal
diarrhea. By midnight, JR again vomitted twice, had loose
Code.
bowel movements and was unable to sleep. The following
Dagupan City, Philippines, January 29, 2001. morning, June 17,2000, JR's condition worsened, he had a
running fever of 38°C. JR's fever remained uncontrolled and xxxx
he became unconscious, he was given Aeknil (1 ampule) and
Valium (1 ampule). JR's condition continued to deteriorate Throughout the course of the hospitalization and treatment of
that by 2 o'clock in the afternoon, JR's temperature soared to JR, the accused failed to address the acute appendicitis which
42°C, had convulsions and finally died. was the initial diagnosis. They did not take steps to find out if
indeed acute appendicitis was what was causing the massive
The Death Certificate10 dated June 19, 2000 prepared by Dr. infection that was ongoing inside the body of JR even when
Cabugao indicated the following causes of death: the inflammatory process was located at the paraumbilical
region where the appendix can be located. x x x
Immediate cause: CARDIORESPIRATORY ARREST
There may have been other diseases but the records do not
Antecedent cause: METABOLIC ENCEPHALOPATHY show that the accused took steps to find outwhat disease
Underlying cause: SEPTICEMIA (ACUTE APPENDICITIS) exactly was plaguing JR. It was their duty to find out the
disease causing the health problem of JR, but they did not
Other significant conditionscontributing to death: perform any process of elimination. Appendicitis, according
to expert testimonies, could be eliminated only by surgery but
CEREBRAL ANEURYSM RUPTURED (?)
no surgery was done by the accused. But the accused could
No post-mortem examination was conducted on JR. On not have found out the real disease of JR because they were
February 1, 2001, an Information was filed against accused treating merely and exclusively the symptoms by means of the
for reckless imprudence resulting to homicide. At their different medications to arrest the manifested symptoms. In
arraignment, both accused, duly assisted by counsel, pleaded fact, by treating the symptoms alone, the accused were
not guilty to the charge. recklessly and wantonly ignoring the same as signs of the
graver health problem of JR. This gross negligence on the part
On February 28, 2003, in convicting both the accused, the trial of the accused allowed the infection to spread inside the body
court found the following circumstances as sufficient basis to of JR unabated. The infection obviously spread so fastand was
conclude that accused were indeed negligent in the so massive that within a period of only two and a half (2 ½)
performance of their duties: days from the day of admission to the hospital on June 15,
2000, JR who was otherwise healthy died [of] Septicemia
It is unquestionable that JR was under the medical care of the
(Acute Appendicitis) on June 17, 2000.11
accused from the time of his admission for confinement at the
Nazareth General Hospital until his death. Upon his On June 4, 2004, in affirming the accused' conviction, the
admission, the initial working diagnosis was to consider acute Court of Appeals gave similar observations, to wit:
appendicitis. To assist the accused in the consideration of
acute appendicitis, Dr. Cabugao requested for a complete The foregoing expert testimony clearly revealed such want of
blood count (CBC) and a diagnostic ultrasound on JR. The reasonable skill and care on the part of JR's attending
findings of the CBC and ultrasound showed that an physicians, appellants Dr. Cabugao and Dr. Ynzon in
inflammatory process or infection was going on inside the neglecting to monitor effectively and sufficiently the
body of JR. Said inflammatory process was happening in the developments/changes during the observation period and act
periumbilical region where the appendix could be located. The upon the situation after said 24-hour period when his
initial diagnosis of acute appendicitis appears to be a distinct abdominal pain subsisted, his condition even worsened with
possibility. x x x. the appearance of more serious symptoms of nausea, vomiting
and diarrhea. Considering the brief visit only made on regular
Dr. Ynzon ordered medications to treat the symptoms being rounds, the records clearly show such gross negligence in
manifested by JR. Thereafter, he ordered that JR be observed failing to take appropriate steps to determine the real cause of
for 24 hours. However, the accused, as the attending JR's abdominal pain so that the crucial decision to perform
physicians, did not personally monitor JR in order to check on surgery (appendectomy) had even been ruled out precisely
subtle changes that may occur. Rather, they left the because of the inexcusable neglect to undertake suchefficient
monitoring and actual observation to resident physicians who diagnosis by process of elimination, as correctly pointed out
are just on residency training and in doing so, they substituted by the trial court. As has been succinctly emphasized by Dr.
their own expertise, skill and competence with those of Mateo, acute appendicitis was the working diagnosis, and with
physicians who are merely new doctors still on training. Not the emergence of symptoms after the 24-hour observation
having personally observed JR during this 24-hour critical (high fever, vomiting, diarrhea) still, appellants ruled out
period of observation, the accused relinquished their duty and surgery, not even considering exploratory laparoscopy. Dr.
thereby were unable to give the proper and correct evaluation Mateo also expressed the opinion that the decision to operate
as to the real condition of JR. In situations where massive could have been made after the result of the ultrasound test,
infection is going on as shown by the aggressive medication considering that acute appendicitis was the initial diagnosis by
of antibiotics, the condition of the patient is serious which Dr. Cabugao after he had conducted a rectal examination.
necessitated personal, not delegated, attention of attending
physicians, namely JR and the accused in this case. Medical records buttress the trial court's finding that in
treating JR, appellants have demonstrated indifference and EXCLUDED SURGERY FROM THE LIMITS OFHIS
neglect of the patient's condition as a serious case. Indeed, PRACTICE, AND IT WAS NOT AND NEVER HIS DUTY
appendicitis remains a clinical emergencyand a surgical TO OPERATE THE PATIENT RODOLFO PALMA JR.,
disease, as correctly underscored by Dr. Mateo, a practicing THAT WAS WHY HE REFERRED SUBJECT PATIENT
surgeon who has already performed over a thousand TO A SURGEON, DR. CLENIO YNZON;
appendectomy. In fact, appendectomy is the only rational
therapy for acute appendicitis; it avoids clinical deterioration IV
and may avoid chronic or recurrent appendicitis. Although WHETHER THE DEFENSE NEVER STATED THAT
difficult, prompt recognition and immediate treatment of the THERE IS GUARANTEE THAT DOING SURGERY
disease prevent complications. Under the factual WOULD HAVE SAVED THE PATIENT;
circumstances, the inaction, neglect and indifference of
appellants who, after the day of admission and after being V
apprised of the ongoing infection from the CBC and initial
WHETHER THE WITNESSES FOR THE PROSECUTION
diagnosis as acute appendicitis from rectal examination and
INCLUDING PROSECUTION'S EXPERT WITNESSES
ultrasound testand only briefly visited JR once during regular
EVER DECLARED/TESTIFIED THAT PETITIONER DR.
rounds and gave medication orders by telephone – constitutes
CABUGAO HAD THE DUTY TO PERFORM IMMEDIATE
gross negligenceleading to the continued deterioration of the
OPERATION ON RODOLFO PALMA, JR., AND THEY
patient, his infection having spread in sofast a pace that he
FAILED TO STATE/SHOW THAT THE PROXIMATE
died within just two and a half (2 ½) days’ stay inthe hospital.
CAUSE OF DEATH OF JR WAS ACUTE APPENDICITIS;
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 VI
improve diagnostic accuracy and help to hasten
diagnosis.Even assuming that JR's case had an atypical WHETHER THE EXPERT WITNESSES PRESENTED BY
presentation in view of the location of his appendix, THE PROSECUTION EVER QUESTIONED THE
laboratory tests could have helped to confirm diagnosis, as Dr. MANAGEMENT AND CARE APPLIED BY PETITIONER
Mateo opined thatthe possibility of JR having a retrocecal DR. CABUGAO;
appendicitis should have been a strong consideration.
VII
Lamentably, however, as found by the trial court, appellants
had not taken steps towards correct diagnosis and WHETHER THE EXPERT WITNESSES PRESENTED BY
demonstrated laxity even when JR was already running a high THE DEFENSE ARE UNANIMOUS IN APPROVING THE
fever in the morning of June 17, 2000 and continued vomiting METHOD OF TREATMENT APPLIED BY BOTH
with diarrhea, his abdominal pain becoming more intense. ACCUSED DOCTORS ON SUBJECT PATIENT, AND
This is the reason why private complainants were not even THEY DECLARED/AFFIRMED THAT THEY WOULD
apprised of the progress of appellants' diagnosis – appellants FIRST PLACE SUBJECT THE PATIENT UNDER
have nothing to report because they did nothing towards the OBSERVATION, AND WOULD NOT PERFORM
end and merely gave medications to address the symptoms.12 IMMEDIATE OPERATION;
Thus, these appeals brought beforethis Court raising the VIII
following arguments:
WHETHER THE CONVICTION OF PETITIONER DR.
I YNZON WAS ESTABLISHED WITH THE REQUIRED
QUANTUM OF PROOF BEYOND REASONABLE DOUBT
WHETHER THE CAUSE OF ACCUSATION AS
THAT THE PATIENT WAS SPECIFICALLY SUFFERING
CONTAINED IN THE INFORMATION IS "FAILURE TO
FROM AND DIED OF ACUTE APPENDICITIS; and
PERFORM IMMEDIATE OPERATION UPON THE
PATIENT ROFOLFO PALMA JR. OF ACUTE IX
APPENDICITIS;
WHETHER THE FAILURE TO CONDUCT THE SPECIFIC
II SURGICAL OPERATION KNOWN AS APPENDECTOMY
CONSTITUTED CRIMINAL NEGLIGENCE.
WHETHER THE SUBJECT INFORMATION APPEARS TO
HAVE ACCUSED BOTH ACCUSED DOCTORS OF In a nutshell, the petition brought before this Court raises the
CONSPIRACY AND THE APPEALED DECISION SEEMS issue of whether or not petitioners' conviction of the crime of
TO HAVE TREATED BOTH ACCUSED DOCTORS TO BE reckless imprudence resulting in homicide, arising from
IN CONSPIRACY; analleged medical malpractice, is supported by the evidence
on record.
III
Worth noting is that the assigned errors are actually factual in
WHETHER PETITIONER DR. CABUGAO IS A GENERAL
nature, which as a general rule, findings of factof the trial
PRACTITIONER (NOT A SURGEON) AND HAVE
court and the Court of Appeals are binding and Q If unchecked doctor, what will happen?
conclusiveupon this Court, and we will not normally disturb
such factual findings unless the findings of the court are A It will result to death.17
palpably unsupported by the evidence on record or unless the xxxx
judgment itself is based on misapprehension of facts. Inthe
instant case, we find the need to make certain exception. Q And what would have you doneif you entertain other
considerations from the time the patient was admitted?
AS TO DR. YNZON'S LIABILITY:
A From the time the patient was admitted until the report of
Reckless imprudence consists of voluntarily doing or failing the sonologist, I would have made a decision by then.
to do, without malice, an act from which material damage
results by reason of an inexcusable lack of precautionon the Q And when to decide the surgery would it be a particular
part of the person performing or failing to perform such exact time, would it be the same for all surgeons?
act.13 The elements of reckless imprudence are: (1) that the
A If you are asking acute appendicitis, it would be about 24
offender does or fails to do an act; (2) that the doing or the
hours because acute appendicitis is a 24-hour disease, sir.
failure to do that act is voluntary; (3) that it bewithout malice;
(4) that material damage results from the reckless imprudence; Q. And would it be correct to say that it depends on the
and (5) that there is inexcusable lack of precaution on the part changes on the condition of the patient?
of the offender, taking into consideration his employment or
occupation, degree of intelligence, physical condition, and A. Yes, sir.
other circumstances regarding persons, time and place.14
Q. So, are you saying more than 24 hours when there are
With respect to Dr. Ynzon, all the requisites of the offense changes?
have been clearly established by the evidence on record. The
A. If there are changes in the patient pointing towards
court a quoand the appellate court were one in concluding that
appendicitis then you have to decide right there and then, sir.
Dr. Ynzon failed to observe the required standard of care
expected from doctors. Q. So if there are changes in the patient pointing to
appendicitis?
In the instant case, it was sufficiently established that to
prevent certain death, it was necessary to perform surgery on A. It depends now on what you are trying to wait for in the
JR immediately. Even the prosecution’s own expert witness, observation period, sir.
Dr. Antonio Mateo,15 testified during cross-examination that
he would perform surgery on JR: Q. So precisely if the change is a condition which bring you in
doubt that there is something else other than appendicitis,
ATTY. CASTRO: would you extend over a period of 24 hours?
Q. Given these data soft non-tender abdomen, ambulatory, A. It depends on the emergent development, sir.
watery diarrhea, Exhibit C which is the ultrasound result, with
that laboratory would you operate the patient? Q. That is the point, if you are the attending physician and
there is a change not pointing to appendicitis, would you
A Yes, I would do surgery. extend over a period of 24 hours?
Q And you should have done surgery with this particular A. In 24 hours you have to decide, sir.
case?"
xxxx
A Yes, sir.16
Q. And that is based on the assessment of the attending
xxxx physician?
COURT: A. Yes, sir.18
Q You stated a while ago doctor thatyou are going to [do] Dr. Mateo further testified on cross-examination:
surgery to the patient, why doctor, if you are notgoing to do
surgery, what will happen? ATTY. CASTRO:

A If this would be appendicitis, the usual progress would be Q: So you will know yourself, as far as the record is
that it would be ruptured and generalized peritonitis and concerned, because if you will agree with me, you did not
eventually septicemia, sir. even touch the patient?

Q What do you mean by that doctor? A. Yes, I based my opinion on what is put on record, sir. The
records show that after the observation period, the abdominal
A That means that infection would spread throughout the pain is still there plus there are already other signs and
body, sir. symptoms which are not seen or noted.
Q. But insofar as you yourself not having touched the A. You have to correlate all the findings.
abdomen of the patient, would you give a comment on that?
Q. Is it yes or no, Doctor?
A. Yes, based on the record, after 24 hours of observation, the
pain apparently was still there and there was more vomiting A. Yes.
and there was diarrhea. In my personal opinion, I think the Q. So, you are saying then that in order to rule out acute
condition of the patient was deteriorating. appendicitis there must be an operation, that is right Doctor?
Q. Even though you have not touched the patient? A. No, sir. If your diagnosis is toreally determine if it is an
A. I based on what was on the record, sir.19 acute appendicitis, you have to operate.21

From the foregoing, it is clear that if JR’s condition remained xxxx

unchecked it would ultimately result in his death, as what Q. Now Doctor, considering the infection, considering that
actually happened in the present case. Another expert witness there was a [symptom] that causes pain, considering that JR
for the defense, Dr. Vivencio Villaflor, Jr. testified on direct likewise was feverish and that he was vomiting, does that not
examination that he would perform a personal and thorough show a disease of acute appendicitis Doctor?
physical examination of the patient as frequent as every 4 to 6
hours, to wit: A. Its possible.

ATTY. CASTRO: Q. So that if that is possible, are we getting the impression

then Doctor what you have earlier mentioned that the only
Q. As an expert doctor, if you were faced with a history of way to rule out the suspect which is acute appendicitis is by
abdominal pain with nausea, vomiting, fever, anurecia (sic), surgery, you have said that earlier Doctor, I just want any
elevated white blood cell count, physical examination of a confirmation of it?
positive psoas sign, observation of the sonologist of
abdominal tenderness and the ultrasound findings of the A. Yes, sir.22
probability of appendiceal (sic) pathology, what will you do if
Verily, whether a physician or surgeon has exercised the
you have faced these problems, Doctor?
requisite degree of skill and care in the treatment of his patient
A. I will examine the patient thoroughly and it will depend on is, in the generality of cases, a matter of expert opinion. The
my physical examination and that isprobably every 4 to 6 deference of courts to the expert opinions of qualified
hours, sir.20 physicians stems from its realization that the latter possess
unusual technical skills which laymen in most instances are
On cross-examination, Dr. Villaflor affirmed: incapable of intelligently evaluating.23 From the testimonies of
Cross Exam. By Atty. Marteja: the expert witnesses presented, it was irrefutably proven that
Dr. Ynzon failed to practice that degree of skill and care
Q. x x x However, there are corrections and admissions made required in the treatment of his patient.
at that time, your Honor, do I understand thatT/C does not
mean ruled out but rather to consider the matter? As correctly observed by the appellate court, Dr. Ynzon
revealed want of reasonable skill and care in attending to the
A. Yes, now that I have seen the records of the patient, it says needs of JR by neglecting to monitor effectively the
here, impression and T/C means to consider the appendicitis. developmentsand changes on JR's condition during the
observation period, and to act upon the situation after the 24-
Q. Isn't it that it is worth then to say that the initial working hour period when his abdominal pain persisted and his
diagnosis on Rodolfo Palma, Jr., otherwise known as JR, to condition worsened. Lamentable, Dr. Ynzon appeared to have
whom I shall now refer to as JR, the primary consideration visited JRbriefly only during regular rounds in the mornings.
then is acute appendicitis, is that correct to say Doctor? He was not there during the crucial times on June 16, 2000
A. I think so, that is the impression. when JR's condition started to deteriorate until JR's death. As
the attending surgeon, he should be primarily responsible in
Q. x x x Now if it is to be considered as the primary monitoring the condition of JR, as he is in the best position
consideration in the initial working diagnosis, isn't it a fact considering his skills and experience to know if the patient's
that it has tobe ruled out in order to consider it as not the condition had deteriorated. While the resident-doctors-onduty
disease of JR? could likewise monitor the patient’scondition, he is the one
directly responsible for the patient as the attending surgeon.
A. Yes. Sir.
Indeed, it is reckless and gross negligence of duty to relegate
Q. Isn't it a fact thatto rule out acute appendicitis as not the his personal responsibility to observe the condition of the
disease of JR, surgery or operation must be done, isn't it patient. Again, acute appendicitis was the working diagnosis,
Doctor? and with the emergence of graver symptoms after the 24-hour
observation, Dr. Ynzon ruled out surgery for no apparent
reason. We, likewise, note that the records are devoid of appendectomy.
showing of any reasonable cause which would lead Dr. Ynzon
tooverrule appendectomy despite the initial diagnosis of Immediately apparent from a review of the records of this case
appendicitis. Neitherwas there any showing that he was is the fact that Dr. Cabugao is not a surgeon,but a general
entertaining another diagnosis nor he took appropriate steps practitioner specializing in family medicine;27 thus, even if he
towards another diagnosis. wanted to, he cannot do an operation, much less an
appendectomy on JR. It is precisely for this reason why he
Among the elements constitutive of reckless imprudence, referred JR to Dr. Ynzon after he suspected appendicitis. Dr.
what perhaps is most central to a finding of guilt is the Mateo, the prosecution’s expert witness, emphasized the role
conclusive determination that the accused has exhibited, by of the surgeon during direct examination, to wit:
his voluntary act without malice, an inexcusable lack of
precaution. It is that which supplies the criminal intent so ATTY. MARTEJA:
indispensable as tobring an act of mere negligence and Q. You had mentioned that under this circumstances and
imprudence under the operation of the penal law. This is condition, you have mentioned that surgery is the solution,
because a conscious indifference to the consequences of the would you have allowed then a 24 hour observation?
conduct is all that is required from the standpoint of the frame
of mind of the accused. 24 Quasioffenses penalize the mental A. If there is a lingering doubt, inshort period of observation
attitudeor condition behind the act, the dangerous of 18-24 hours can be allowed provided that there would be
recklessness, the lack of care or foresight, the "imprudencia close monitoring of the patient, sir.
punible," unlike willful offenses which punish the intentional
Q. Would you please tell us who would be doing the
criminal act.25 This is precisely where this Court found Dr.
monitoring doctor?
Ynzon to be guilty of - his seemingly indifference to the
deteriorating condition of JR that he as a consequence, failed A. The best person should be the first examiner, the best
to exercise lack of precaution which eventually led to JR's surgeon, sir.
death.
Q. So that would you say that it is incumbent on the surgeon
To be sure, whether or not a physician has committed an attending to the case to have been the one to observe within
"inexcusable lack of precaution" in the treatment of his patient the period of observation?
is to be determined according to the standard of care observed
by other members of the profession in good standing under A. Yes, because he will be in the best position to observe the
similar circumstances bearing in mind the advanced state of sudden changes in the condition of the patient, sir.
the profession at the time of treatment or the present state of
Q. And how often would in your experience doctor, how often
medical science. In accepting a case, a doctor in effect
would the surgeon re-assist (sic) the condition of the patient
represents that, having the needed training and skill possessed
during the period of observation?
by physicians and surgeons practicing in the same field, he
will employ such training, care and skill in the treatment of his A. Most foreign authors would recommend every four (4)
patients. He, therefore, has a duty to use at least the same level hours, some centers will recommend hourly or every two
of care that any other reasonably competent doctor would use hours but here in the Philippines, would recommend for 4 to 6
to treat a condition under the same circumstances. 26 Sadly, Dr. hours, sir.28
Ynzon did not display that degree of care and precaution
demanded by the circumstances. Dr. Cabugao’s supervision does not cease upon his
endorsement of his patient to the surgeon. Here, Dr. Cabugao
AS TO DR. CABUGAO'S LIABILITY: has shown to have exerted all efforts to monitor his patient
and under these circumstances he did not have any cause to
Every criminal conviction requires of the prosecution to prove
doubt Dr. Ynzon’s competence and diligence. Expert
two things — the fact of the crime, i.e., the presence of all the
testimonies have been offered to prove the circumstances
elements of the crime for which the accused stands charged,
surrounding the case of JR and the need to perform an
and the fact that the accused is the perpetrator of the crime.
operation. Defense witness, Dr. Villaflor, on cross
Based on the above disquisitions, however, the prosecution
examination testified, to wit:
failed to prove these two things. The Court is not convinced
with moral certainty that Dr. Cabugao isguilty of reckless Q. Isn't it a fact that torule out acute appendicitis as notthe
imprudence as the elements thereof were not proven by the disease of JR, surgery or operation mustbe done, isn't it
prosecution beyond a reasonable doubt. Doctor?
Both the trial court and the appellate court bewail the failure A. You have to [correlate] all the findings.
to perform appendectomy on JR, or the failure to determine
the source of infection which caused the deterioration of JR's Q. Is it yes or no, Doctor?
condition. However, a review of the records fail to show that
A. Yes.
Dr. Cabugao is in any position to perform the required
Q. So, you are saying then that in order to rule out acute While this case is pending appeal, counsel for petitioner Dr.
appendicitis there must be an operation, that is right Doctor? Ynzon informed the Court that the latter died on December
23, 2011 due to "multiorgan failure" as evidenced by a copy
A. No, sir. If your diagnosis is to really determine if it is an of death certificate.33 Thus, the effect of death, pending appeal
acute appendicitis, you have to operate.29 of his conviction of petitioner Dr. Ynzon with regard to his
xxxx criminal and pecuniary liabilities should be in accordance to
People v. Bayotas,34 wherein the Court laid down the rules in
Q. Now Doctor, considering the infection, considering that case the accused dies prior to final judgment:
there was a [symptom] that causes pain, considering that JR
likewise was feverish and that he was vomitting, does that not 1. Death of the accused pending appeal of his conviction
show a disease of acute appendicitis Doctor? extinguishes his criminal liability as well as the civil liability
based solely thereon. As opined by Justice Regalado, in this
A. It’s possible. regard, "the death of the accused prior to final judgment
terminates his criminal liability and only the civil liability
Q. So that if that is possible, are we getting the impression
directly arising from and based solely on the offense
then Doctor what you have earlier mentioned that the only
committed, i.e.,civil liability ex delictoin senso strictiore."
way to rule out the suspect which is acute appendicitis is by
surgery, you have said that earlier Doctor, I just want any 2. Corollarily, the claim for civil liability survives
confirmation of it? notwithstanding the death of accused, if the same may also be
predicated on a source of obligation other than delict. Article
A. Yes, sir.30
1157 of the Civil Code enumerates these other sources of
Neither do we find evidence that Dr. Cabugao has been obligation fromwhich the civil liability may arise as a result of
negligent or lacked the necessary precaution in his the same act or omission:
performance of his duty as a family doctor. On the contrary, a
a) Law
perusal ofthe medical records would show that during the 24-
hour monitoring on JR, it was Dr. Cabugao who frequently b) Contracts
made orders on the administration of antibiotics and pain
relievers. There was also repetitive instructions from Dr. c) Quasi-contracts
Cabugao to refer JR to Dr. Ynzon as it appeared that he is d) x x x x x x x x x
suspecting appendicitis. The referral of JR to Dr. Ynzon, a
surgeon, is actually an exercise of precaution as he knew that e) Quasi-delicts
appendicitis is not within his scope of expertise. This clearly
showed that he employed the best of his knowledge and skill 3. Where the civil liability survives, as explained in Number 2
in attending to JR's condition, even after the referral of JR to above, an action for recovery therefor may be pursued but
Dr. Ynzon. To be sure, the calculated assessment of Dr. only by way of filing a separate civil action and subject to
Cabugao to refer JRto a surgeon who has sufficient training Section 1, Rule 111 of the 1985 Rules on Criminal Procedure
and experience to handle JR’s case belies the finding that he as amended. This separate civil action may be enforced either
displayed inexcusable lack of precaution in handling his againstthe executor/administrator or the estate of the accused,
patient.31 depending on the source of obligation upon which the same is
based as explained above.
We likewise note that Dr. Cabugao was out of town when JR's
condition began to deteriorate. Even so, before he left, he 4. Finally, the private offended party need not fear a forfeiture
made endorsement and notified the resident-doctor and of his right to file this separate civil action by prescription, in
nurses-on-duty that he will be on leave. cases where during the prosecution of the criminal action and
prior to its extinction, the private-offended party instituted
Moreover, while both appeared to be the attending physicians together therewith the civil action. In such case, the statute of
of JR during his hospital confinement, it cannot be said that limitationson the civil liability is deemed interrupted during
the finding of guilt on Dr. Ynzon necessitates the same the pendency of the criminal case, conformably with
finding on the co-accused Dr. Cabugao. Conspiracy is provisions of Article 1155 of the Civil Code, that should
inconsistent with the idea of a felony committed by means of thereby avoid any apprehension on a possible privation of
culpa.32 Thus, the accused-doctors to be found guilty of right by prescription.35
reckless imprudence resulting in homicide, it must be shown
that both accused-doctors demonstratedan act executed In view of the foregoing, it is clear that the death of the
without malice or criminal intent – but with lack of foresight, accused Dr. Ynzon pending appeal of his conviction
carelessness, or negligence. Noteworthy, the evidence on extinguishes his criminal liability. However, the recovery of
record clearly points to the reckless imprudence of Dr. Ynzon; civil liability subsists as the same is not based on delictbut by
however, the same cannot be said in Dr. Cabugao's case. contract and the reckless imprudence he was guilty of under
Article 365 of the Revised Penal Code.1âwphi1 For this
AS TO CIVIL LIABILITY reason, a separate civil action may be enforced either against
the executor/administrator or the estate of the accused, expenses and expense for the last sickness of the decedent,
depending on the source of obligation upon which the same is and judgment for money against the decent, must be filed
based,36 and in accordance with Section 4, Rule 111 of the within the time limited in the notice; otherwise they are barred
Rules on Criminal Procedure, we quote: forever, except that they may be set forth as counterclaims in
any action that the executor or administrator may bring
Sec. 4. Effect of death on civil actions. – The death of the against the claimants. Where an executor or administrator
accused after arraignment and during the pendency of the commencesan action, or prosecutes an action already
criminal action shall extinguish the civil liability arising from commenced by the deceased in his lifetime, the debtor may set
the delict. However, the independent civil action instituted forth by answer the claims he has against the decedent, instead
under section 3 of this Rule or which thereafter is instituted to of presenting them independently to the court as herein
enforce liability arising from other sources of obligation may provided, and mutual claims may be set off against each other
be continued against the estate or legal representative of the in such action; and if final judgment is rendered in favor of the
accused after proper substitution or against said estate, as the defendant, the amount so determined shall be considered the
case may be. The heirs of the accused may besubstituted for true balance against the estate, as though the claim had been
the deceased without requiring the appointment of an executor presented directly beforethe court in the administration
or administrator and the court may appoint a guardian ad litem proceedings. Claims not yet due, or contingent, may be
for the minor heirs. approved at their present value.
The court shall forthwith order said legal representative or As a final note, we reiterate thatthe policy against double
representatives to appear and be substituted within a period of recovery requires that only one action be maintained for the
thirty (30) days from notice. same act or omission whether the action is brought against the
A final judgment entered in favor of the offended party shall executor or administrator, or the estate.39 The heirs of JR must
be enforced in the manner especially provided in these rules choose which of the available causes of action for damages
for prosecuting claims against the estate of the deceased. they will bring.

If the accused dies before arraignment, the case shall be WHEREFORE, premises considered, petitioner DR.
dismissed without prejudice to any civil action the offended ANTONIO P. CABUGAO is hereby ACQUITTEDof the
party may file against the estate of the deceased. (Emphases crime of reckless imprudence resulting to homicide.
ours) Due to the death of accused Dr. Clenio Ynzon prior to the
In sum, upon the extinction of the criminal liability and the disposition of this case, his criminal liability is extinguished;
offended party desires to recover damages from the same act however, his civil liability subsists. A separate civil action
or omission complained of, the party may file a separate civil may be filed either against the executor/administrator, or the
action based on the other sources of obligation in accordance estateof Dr. Ynzon, depending on the source of obligation
with Section 4, Rule 111.37 If the same act or omission upon which the same are based.
complained of arises from quasi-delict,as in this case, a SO ORDERED.
separate civil action must be filed against the executor or
administrator of the estate of the accused, pursuant to Section
1, Rule 87 of the Rules of Court:38

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 debtor 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)

Conversely, if the offended party desires to recover damages

from the same act or omission complained of arising from
contract, the filing of a separate civil action must be filed
against the estate, pursuant to Section 5, Rule 86 of the Rules
of Court, to wit:

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