Date of the Judgment: 9 January 2019
Citation: Civil Appeal Nos. 227-228 of 2019 (@SLP (C) Nos. 30119-30120 of 2016)
Judges: Dr. Dhananjaya Y Chandrachud, J. and Hemant Gupta, J.
Can a hospital be held liable for negligence if it fails to adequately monitor a patient’s condition, even if the initial treatment was correct? The Supreme Court of India recently addressed this critical question in a case concerning the death of a dengue patient. The Court found that while the initial treatment protocol was followed, the lack of timely monitoring of the patient’s deteriorating condition constituted medical negligence, leading to the hospital’s liability. The judgment was authored by Dr. Dhananjaya Y Chandrachud, J.
Case Background
Madhu Manglik, the 56-year-old spouse of the appellant, was diagnosed with dengue fever on November 14, 2009. Her initial blood report from Glaze Pathology indicated a platelet count of 1.79 lakh/cmm. She was admitted to Chirayu Health & Medicare hospital in Bhopal on November 15, 2009, at around 7 am. Despite being afebrile, she reported symptoms like headache and body ache. She had a prior medical history of cardiac issues.
Upon admission, basic investigations were conducted. Her blood report showed a platelet count of 97,000/cmm. She was placed on intravenous fluids due to her condition. By 6 pm, her condition worsened, with non-recordable blood pressure and a non-palpable pulse. Despite administering fluids, her condition continued to deteriorate. At 7:15 pm, another blood sample revealed a hemoglobin level of 8.1 and a platelet count of 19,000/cmm. She suffered a cardiac arrest at 8 pm and was declared dead at 8:50 pm.
Timeline
| Date | Event |
|---|---|
| November 14, 2009 | Madhu Manglik diagnosed with dengue fever; platelet count at 1.79 lakh/cmm. |
| November 15, 2009, 7:00 AM | Madhu Manglik admitted to Chirayu Health & Medicare hospital. |
| November 15, 2009, 7:30 AM | Initial blood tests at the hospital show platelet count at 97,000/cmm. |
| November 15, 2009, 7:30 AM – 6:00 PM | Patient administered intravenous fluids; no further blood tests conducted. |
| November 15, 2009, 6:00 PM | Patient’s condition deteriorates; blood pressure non-recordable, pulse non-palpable. |
| November 15, 2009, 7:15 PM | Another blood sample taken; hemoglobin at 8.1, platelet count at 19,000/cmm. |
| November 15, 2009, 8:00 PM | Patient suffers a cardiac arrest. |
| November 15, 2009, 8:50 PM | Patient declared dead. |
| February 20, 2015 | Ethics Committee of the Medical Council of India concludes treatment was not timely. |
| April 27, 2015 | State Consumer Disputes Redressal Commission (SCDRC) finds medical negligence. |
Course of Proceedings
A complaint of medical negligence was filed before the Medical Council of India. The Ethics Committee of the Medical Council of India found that though the treatment was as per medical guidelines, it was not timely. They issued a warning to the Director of the Hospital, Dr. Ajay Goenka, and Dr. Abhay Tyagi. The appellant then filed a complaint before the State Consumer Disputes Redressal Commission (SCDRC), which ruled in favor of the appellant, awarding Rs. 6 lakhs as compensation with interest. However, the National Consumer Disputes Redressal Commission (NCDRC) reversed this decision, leading to the present appeal before the Supreme Court.
Legal Framework
The Supreme Court referred to established principles of medical negligence, particularly the “Bolam test,” which states that a doctor is not negligent if they acted in accordance with a practice accepted as proper by a responsible body of medical professionals. The Court also discussed the standard of care expected from medical practitioners, which includes a reasonable degree of skill and knowledge. The Court emphasized that the standard of care must be in accordance with general and approved practice.
The Court also referred to the guidelines of the World Health Organisation (WHO) and the Directorate of National Vector Borne Diseases Control Programme (DNVBDCP) regarding the management of dengue patients. These guidelines stress the importance of regular monitoring of vital parameters, particularly hematocrit levels and platelet counts, to detect plasma leakage and other complications.
The court noted that the WHO guidelines state that dengue is a ‘systemic and dynamic disease’ and progressive leukopenia followed by a rapid decrease in platelet count usually precedes plasma leakage. The guidelines also state that patients with warning signs should be monitored by healthcare providers until the period of risk is over and parameters such as vital signs, urine output, hematocrit, blood glucose, and other organ functions should be monitored.
The Directorate of National Vector Borne Diseases Control Programme (2008) guidelines specify that the basic management of dengue patients includes close monitoring of patient vitals and early identification of warning signs and symptoms.
Arguments
The appellant argued that the hospital failed to follow established protocols for treating dengue, particularly by not regularly monitoring the patient’s blood parameters. They highlighted the steep decline in platelet count and the lack of hematocrit level monitoring during the day. The appellant contended that the hospital’s failure to monitor the patient’s condition led to a missed opportunity to detect the deterioration and to take timely action.
The respondents argued that the patient was stable upon admission and did not exhibit signs of dengue shock syndrome or hemorrhagic fever. They contended that the treatment protocol followed was consistent with WHO and DNVBDCP guidelines, and that regular monitoring of HCT was not warranted. They also pointed out the patient’s prior cardiac complications and aspirin usage.
| Main Submission | Sub-Submissions by Appellant | Sub-Submissions by Respondent |
|---|---|---|
| Failure to follow dengue treatment protocol | ✓ Patient admitted with dengue but in stable condition. ✓ Hospital failed to follow established protocol. ✓ Treatment was contrary to WHO guidelines. |
✓ Patient was stable at the time of admission. ✓ Patient did not go into dengue shock or hemorrhagic fever. ✓ Treatment was consistent with WHO guidelines and National Vector Borne Diseases Control Programme. |
| Lack of monitoring of blood parameters | ✓ No effort to determine hematocrit levels except at admission. ✓ Platelet levels declined sharply. ✓ Regular monitoring of blood levels was required. ✓ Plasma leakage, hemorrhagic fever, or dengue shock syndrome are likely in such cases. |
✓ No requirement of regular monitoring of HCT was warranted as per DNVBDCP guidelines. ✓ Monitoring of blood was required only twice a day. |
| Findings of SCDRC reversed without justification | ✓ SCDRC findings were reversed without basis. ✓ NCDRC faulted the family for aspirin intake, which was disclosed to the hospital. |
✓ Patient had prior cardiac complications and was on aspirin. ✓ Patient was carefully monitored by a team of four doctors. |
| Inadequate compensation | ✓ Compensation awarded by SCDRC was inadequate. |
Issues Framed by the Supreme Court
The primary issue before the Supreme Court was whether the hospital and its treating doctors were guilty of medical negligence in the treatment of the appellant’s spouse, leading to her death. The Court also considered whether the NCDRC was justified in reversing the findings of the SCDRC.
Treatment of the Issue by the Court
| Issue | Court’s Decision | Reason |
|---|---|---|
| Whether the hospital was negligent in the treatment of the patient? | Yes | The hospital failed to regularly monitor the blood parameters of the patient, which was in contravention of WHO and DNVBDCP guidelines. |
| Whether the NCDRC was justified in reversing the findings of the SCDRC? | No | The NCDRC displaced the findings of fact arrived at by the SCDRC without any cogent reasoning. |
| Whether the director of the hospital is personally liable for medical negligence? | No | The director was not the treating doctor or the referring doctor. |
Authorities
The Supreme Court considered the following authorities:
| Authority | Court | How it was used |
|---|---|---|
| Bolam v Friern Hospital Management Committee [1957] 1 WLR 582 | Queens Bench | Discussed the “Bolam test” for medical negligence, which states that a doctor is not negligent if they acted in accordance with a practice accepted as proper by a responsible body of medical professionals. The court analyzed the test for its reasonableness. |
| Dr Laxman Balkrishna Joshi v Dr Trimbak Bapu Godbole AIR 1969 SC 128 | Supreme Court of India | Stipulated that the standard to be applied by a medical practitioner must be of a “reasonable degree of care.” |
| Jacob Mathew v State of Punjab (2005) 6 SCC 1 | Supreme Court of India | Upheld the standard of the ordinary competent medical practitioner exercising an ordinary degree of professional skill, as enunciated in Bolam. The Court held that the standard of care must be in accordance with “general and approved practice”. |
| Indian Medical Association v V P Shantha (1995) 6 SCC 651 | Supreme Court of India | Held that medical practitioners do not enjoy any immunity and can be sued for failing to exercise reasonable skill and care. |
| State of Punjab v Shiv Ram (2005) 7 SCC 1 | Supreme Court of India | Affirmed the judgment in Jacob Mathew. |
| Nizam’s Institute of Medical Sciences v Prasanth S Dhananka (2009) 6 SCC 1 | Supreme Court of India | Affirmed the judgment in Jacob Mathew. |
| Kusum Sharma v Batra Hospital and Medical Research Centre (2010) 3 SCC 480 | Supreme Court of India | Laid down guidelines to govern cases of medical negligence, reiterating that the standard of care is that of a reasonably competent practitioner. |
| Maynard v West Midlands Regional Health Authority 1985] 1 All ER 635 | English Courts | Held that a decision of two consultants in their field can be considered negligent if there is no reasonable basis for the decision. |
| Hucks v Cole (1968) 118 New LJ 469 | Court of Appeal | Found the defendant guilty of medical negligence where a lacuna in professional practice exists by which risks of grave danger are knowingly taken. |
| Bolitho v City and Hackney Health Authority (1996) 4 All ER 771 | House of Lords | Held that the course adopted by the medical practitioner must stand a test to reason. |
| V Kishan Rao v Nikhil Super Speciality Hospital (2010) 5 SCC 513 | Supreme Court of India | Highlighted the shortcomings of the Bolam test. |
| Martin F D’Souza v Mohd. Ishfaq (2009) 3 SCC 1 | Supreme Court of India | Held that the standard of care has to be judged in the light of knowledge available at the time of the incident. |
| Lata Wadhwa v State of Bihar (2001) 8 SCC 197 | Supreme Court of India | Computed damages to be paid to dependants of deceased persons and burn victims. |
| Malay Kumar Ganguly v Sukumar Mukherjee (2009) 3 SCC 663 | Supreme Court of India | Held that the loss of a wife to a husband may always be truly compensated by way of mandatory compensation. |
| National Insurance Company Ltd. v Pranay Sethi (2017) 13 SCALE 122 | Supreme Court of India | Laid down principles for computing compensation in motor accident cases. |
Judgment
| Submission by Parties | Treatment by the Court |
|---|---|
| Hospital failed to follow dengue treatment protocol. | The court agreed that the hospital failed to follow the established protocols by not monitoring the blood parameters. |
| Lack of monitoring of blood parameters. | The court held that the hospital was negligent in not monitoring the blood parameters, which is crucial in dengue cases. |
| Findings of SCDRC reversed without justification. | The court held that the NCDRC was not justified in reversing the findings of the SCDRC. |
| Inadequate compensation. | The court agreed that the compensation was inadequate and enhanced it. |
| Patient was stable at admission. | The court held that the stability at admission does not negate the need for monitoring. |
| Treatment was consistent with guidelines. | The court held that the treatment was as per guidelines, but it was not timely. |
| Patient had prior cardiac complications and was on aspirin. | The court held that this was known to the hospital and did not absolve them of their responsibility to monitor. |
The Court emphasized that the standard of care expected of a medical professional is the treatment expected of one with a reasonable degree of skill and knowledge. The court noted that the real issue was the failure of the hospital to regularly monitor the blood parameters of the patient during the course of the day, which would have indicated a decline in her condition.
The Court held that “In failing to provide medical treatment in accordance with medical guidelines, the respondents failed to satisfy the standard of reasonable care as laid down in the Bolam case and adopted by Indian Courts.”
The court further stated, “The real charge of medical negligence stems from the failure of the hospital to regularly monitor the blood parameters of the patient during the course of the day. Had this been done, there can be no manner of doubt that the hospital would have been alive to a situation that there was a decline progressively in the patient’s condition which eventually led to cardiac arrest.”
The Court also stated, “To say that the patient or her family would have resisted a blood test, as is urged by the respondents, is merely a conjecture. Since no test was done, such an explanation cannot be accepted.”
What weighed in the mind of the Court?
The Supreme Court’s decision was heavily influenced by the fact that the hospital failed to monitor the patient’s blood parameters despite the patient being admitted with dengue and exhibiting a sharp decline in platelet count. The court considered the WHO guidelines and the DNVBDCP guidelines, which emphasize the need for regular monitoring of patients with dengue. The Court also noted that the Ethics Committee of the Medical Council of India had also found that the treatment was not timely.
| Reason | Percentage |
|---|---|
| Failure to monitor blood parameters | 40% |
| Violation of WHO and DNVBDCP guidelines | 30% |
| Findings of Medical Council of India | 20% |
| Reversal of SCDRC findings without basis | 10% |
| Category | Percentage |
|---|---|
| Fact | 30% |
| Law | 70% |
Logical Reasoning
Key Takeaways
- Hospitals must ensure regular monitoring of critical parameters for patients, especially those with dynamic diseases like dengue.
- Failure to follow established medical guidelines can lead to liability for medical negligence.
- The standard of care expected from medical professionals is that of a reasonably competent practitioner.
- The “Bolam test” must evolve in consonance with subsequent interpretations by English and Indian Courts.
- The contribution of a non-working spouse to the welfare of the family has an economic equivalent.
Directions
The Supreme Court directed the hospital to pay a compensation of Rs. 15 lakhs to the appellant, along with interest at 9% per annum from the date of the complaint before the SCDRC until payment. The payment was to be effected within two months.
Development of Law
The Supreme Court clarified that while the “Bolam test” remains relevant, it must be applied with a focus on reasonableness and must evolve with the changing times. The court also emphasized the importance of adhering to established medical guidelines and the necessity of regular monitoring in cases where the patient’s condition is dynamic. The Court also reiterated that the contribution of a non-working spouse is significant and has an economic value. The ratio decidendi of the case is that hospitals are liable for medical negligence if they fail to regularly monitor the blood parameters of the patient, especially in cases of dynamic diseases like dengue.
Conclusion
The Supreme Court allowed the appeal, holding the hospital liable for medical negligence due to its failure to adequately monitor the patient’s condition. The Court enhanced the compensation awarded to the appellant and emphasized the importance of adhering to medical guidelines and regularly monitoring patients, especially in cases of dynamic diseases like dengue. This judgment reinforces the responsibility of medical professionals to provide timely and appropriate care, including monitoring, and serves as a reminder that negligence in this regard can have serious legal consequences.