Supreme Court finds Doctor Negligent in Post-Surgery Complications Case: Harnek Singh & Ors. vs. Gurmit Singh & Ors. (2022)

Introduction

Date of the Judgment: May 18, 2022

Citation: 2022 INSC 453

Judges: Uday Umesh Lalit, S. Ravindra Bhat, Pamidighantam Sri Narasimha

Can a doctor be held liable for negligence if a patient develops complications after surgery? The Supreme Court of India recently addressed this critical question in a case involving a patient who died following a laparoscopic cholecystectomy. The court examined the evidence, medical records, and the report of the ethics committee of the Medical Council of India (MCI) to determine if there was a deficiency of service and medical negligence on the part of the doctor and the hospital. The judgment was delivered by a three-judge bench comprising Justices Uday Umesh Lalit, S. Ravindra Bhat, and Pamidighantam Sri Narasimha, with Justice Uday Umesh Lalit authoring the opinion.

Case Background

The case revolves around the death of Mrs. Manjit Kaur, who was 47 years old and a government teacher. She experienced abdominal pain, and an ultrasound revealed gall bladder stones. On July 13, 2004, she consulted Dr. Gurmit Singh, a laparoscopic surgeon at Preet Surgical Centre & Maternity Hospital. After initial examinations, Dr. Singh recommended surgery to remove the gall bladder stones.

Following the initial consultation, Mrs. Kaur underwent several tests. Dr. Singh requested a second ultrasound from a specific center on July 23, 2004, as he was not satisfied with the first one. After reviewing these results, he advised a consultation with a cardiologist, Dr. Dharamvira Gandhi, due to slightly elevated blood pressure. On July 26, 2004, Dr. Gandhi cleared Mrs. Kaur for surgery.

On July 28, 2004, Dr. Singh performed a laparoscopic cholecystectomy and placed a drain in Mrs. Kaur’s abdomen. The following day, she complained of abdominal pain and distension. The drainage tube showed a greenish fluid discharge, which later turned greenish-brown. Dr. Singh assured the family that this was normal. However, on July 30, 2004, Mrs. Kaur’s condition worsened, with severe pain, distension, and breathing difficulties. Despite the family’s request, Dr. Singh did not seek a second opinion or refer her to another hospital, instead diagnosing acute pancreatitis. The family, unconvinced due to the brown discharge and the patient’s symptoms, again requested a second opinion or transfer.

Finally, on the evening of July 30, 2004, Dr. Singh transferred Mrs. Kaur to Dayanand Medical College and Hospital in Ludhiana, referring her to Dr. Atul Mishra. Dr. Singh declined to provide detailed records, stating that the patient’s condition had been explained to Dr. Mishra. Upon admission, Dr. Punit Gupta suspected an iatrogenic injury to the bile duct and possibly the intestine. A CT scan revealed intra-abdominal and sub-phrenic collection. Dr. Mishra examined the patient on the morning of August 1, 2004. Due to multiple ailments, immediate surgery was not advised.

On August 2, 2004, Mrs. Kaur’s condition became critical, showing signs of colonic perforation. The bilious drain fluid became feculent and foul-smelling. On August 3, 2004, an emergency laparotomy was performed. Dr. Mishra informed the family of a large collection of intestinal contents due to a colon injury, and a bile duct injury that would require a subsequent surgery. Mrs. Kaur’s condition continued to deteriorate, leading to multi-organ failure and her death on August 11, 2004. Dr. Mishra attributed the death to intra-operative injuries to the colon and bile duct, resulting in Peritonitis, Peritoneal Collection, Septicaemia, and Multi-Organ failure.

Timeline:

Course of Proceedings

The complainant filed a consumer complaint before the State Consumer Disputes Redressal Commission (SCDRC), Punjab, on February 14, 2005, which was later transferred to the State Consumer Commission, U.T. Chandigarh. The complainant sought monetary compensation of Rs. 62,85,160 for negligence and deficiency of services. The SCDRC ruled in favor of the complainant, finding Dr. Gurmit Singh and Preet Surgical Centre & Maternity Hospital (Respondents 1 and 2) negligent and directed them to pay Rs. 15,44,000 jointly and severally, along with Rs. 10,000 as costs. The SCDRC found that the CT scan performed on July 31, 2004, showed pneumo peritoneum, indicating an intestinal injury, and concluded that the intra-operative injury to the bile duct and colon caused by Dr. Singh led to the patient’s death. However, the SCDRC exonerated Dr. Atul Mishra and Dayanand Medical College and Hospital (Respondents 3 and 4), finding no negligence on their part.

The complainants appealed to the National Consumer Disputes Redressal Commission (NCDRC), and simultaneously, Respondents 1 and 2 also filed an appeal for dismissal of the complaint. While the proceedings were ongoing at the SCDRC, the complainants also filed a complaint with the Punjab State Medical Council against the professional misconduct of the respondents, which was summarily dismissed on June 13, 2006. The complainants then appealed to the Medical Council of India (MCI). The MCI considered the appeal and asked Respondents 1 and 3 to appear before the Ethics Committee. The Ethics Committee, after reviewing the matter, found Dr. Singh medically negligent and issued a strict warning. Dr. Mishra was exonerated as no medical negligence was proven against him.

The NCDRC heard both appeals together. It observed that the CT scan report of July 31, 2004, did not show any evidence of injury or perforation peritonitis. The NCDRC allowed the appeal of Respondents 1 and 2, setting aside the order of the SCDRC, holding that negligence was not proven by the complainants. The NCDRC found that the patient was not fit for diagnostic laparoscopy immediately, and that Respondents 3 and 4 acted with due care, finding no negligence on their part. The present appeals before the Supreme Court arise from this decision of the NCDRC.

Legal Framework

This case primarily deals with the concept of medical negligence and deficiency of service under the Consumer Protection Act. The legal framework revolves around the duty of care that a medical practitioner owes to their patient. This duty requires doctors to exercise a reasonable degree of skill and care in the treatment of their patients. Failure to do so, resulting in harm to the patient, constitutes medical negligence. The Consumer Protection Act provides a remedy for patients who suffer due to such negligence, allowing them to claim compensation for the harm suffered.

The Supreme Court, in this case, also considered the findings of the Medical Council of India (MCI), which is a statutory body responsible for regulating the medical profession and ensuring ethical conduct by doctors. The MCI’s findings on professional misconduct and negligence carry significant weight in cases involving medical negligence.

Arguments

Appellants’ (Complainants’) Submissions:

• The patient suffered two iatrogenic injuries during the first surgery, one to the colon and the other to the bile duct, leading to fluid accumulation in the peritoneal cavity and discharge from the drain.
• After the patient became critical, Dr. Gurmit Singh referred her to a hospital 100 km away instead of a nearer local hospital.
• Dr. Gurmit Singh admitted in his cross-examination that it did not occur to him that the injuries could take place during the surgery.
• Dr. Atul Mishra negligently delayed the re-exploration surgery even after receiving the CT scan report.
• The NCDRC gave its decision without referring to the MCI findings. Reliance was placed on the judgment of the Supreme Court in Maharaja Agrasen Hospital and Ors. v. Master Rishabh Sharma and Ors. [2020] 6 SCC 501.

Respondents 1 and 2 (Dr. Gurmit Singh and Preet Surgical Centre & Maternity Hospital) Submissions:

• A biliary leak does not necessarily mean a bile duct injury, as it can occur from other areas.
• Specific symptoms of a large intestine leakage were not present, ruling out a colon leakage.
• The rent in the hepatic flexure of the colon may be due to delayed manifestation of thermal injury from electro-cautery or a rare injury from the drainage tube.

Respondents 3 and 4 (Dr. Atul Mishra and Dayanand Medical College and Hospital) Submissions:

• The only allegation was a delay in diagnosing the colonic perforation and corrective surgery, which is incorrect as per the findings of the MCI, SCDRC, and NCDRC.
• The surgery was performed diligently and with due care.
• The bile leak occurred during the first surgery by Dr. Gurmit Singh.
• Immediate surgical intervention was not advised when the patient was admitted to the hospital due to her critical condition. However, when fecal matter leak was found, the patient was immediately operated on.

Submissions Table

Issues Framed by the Supreme Court

The Supreme Court did not explicitly frame issues in a separate section. However, the core issue that the court addressed was:

1. Whether the complainants have established professional negligence on the part of Respondents 1 and 2 as per the standards governing the duty to care of a medical practitioner.

Treatment of the Issue by the Court

The following table demonstrates as to how the Court decided the issues

Authorities

The Supreme Court relied on the following authorities:

Expert Opinions:

• Opinion of Professor and HOD, Department of Surgery, AIIMS, New Delhi.
• Opinion of Professor and HOD, Surgery, KGMC Lucknow.

Cases:

• Maharaja Agrasen Hospital and Ors. v. Master Rishabh Sharma and Ors. [2020] 6 SCC 501 – Supreme Court of India
• Kusum Sharma & Others v. Batra Hospital & Medical Research Centre and others [2010] 3 SCC 480 – Supreme Court of India
• Jacob Mathew v. State of Punjab [2005] 6 SCC 1 – Supreme Court of India
• Achutrao Haribhau Khodwa and others v. State of Maharashtra and others [1996] 2 SCC 634 – Supreme Court of India
• S.K. Jhunjhunwala v. Dhanwanti Kaur [2019] 2 SCC 282 – Supreme Court of India

Authorities Considered by the Court

Judgment

How each submission made by the Parties was treated by the Court?

How each authority was viewed by the Court?

What weighed in the mind of the Court?

The Supreme Court’s decision was heavily influenced by the findings of the Medical Council of India (MCI) and the expert opinions provided by Professors from AIIMS, New Delhi, and KGMC, Lucknow. The court emphasized that the NCDRC failed to consider the MCI report, which clearly established medical negligence on the part of Dr. Gurmit Singh. The court also highlighted Dr. Singh’s admission during cross-examination that he did not consider the possibility of intra-operative injuries, indicating a lack of due care. The court found that there was a large bowel perforation after the laparoscopic operation and that there was a failure to suspect the occurrence of complications despite warning signs and symptoms. The court also noted that the shifting of the patient to a distant hospital was not appropriate. These factors, along with the expert opinions, weighed heavily in the court’s decision to hold Dr. Singh and the hospital negligent.

Sentiment Analysis of Reasons

Fact:Law Ratio

Fact: Percentage of the consideration of the factual aspects of the case.

Law: Percentage of legal considerations.

Logical Reasoning

The court’s reasoning was based on a step-by-step analysis of the facts, expert opinions, and the MCI report. The court rejected the NCDRC’s findings, emphasizing the importance of considering the MCI’s conclusions in cases of medical negligence. The court also highlighted the lack of due care on the part of Dr. Singh, based on his own admissions and the expert opinions.

The court considered the possibility of other causes for the complications, such as thermal injury or an injury from the drainage tube, but rejected these explanations based on the evidence and expert opinions. The court concluded that the injuries were a result of negligence during the surgery and the failure to detect and address the complications promptly.

The court’s decision was unanimous, with all three judges agreeing on the outcome. There were no dissenting opinions.

The Supreme Court held that the complainants have made out a case of medical negligence against Respondents 1 and 2 and are entitled to seek compensation on the ground of deficiency of service. The court set aside the decision of the NCDRC and restored the findings of the SCDRC, with modifications to the compensation amount.

The court quoted the following from the MCI report:

• “There was a large bowel perforation after the laparoscopic operation. This complication which though not known in the normal course of time, had occurred in this particular case. This complication could have been prevented if care had been exercised during the procedure by Dr. Gurmit Singh.”
• “More important Dr. Gurmit has failed to suspect the occurrence of complications despite following warning, signs/symptoms- i)the patient not recovering after the operation. ii)the patient increasingly deteriorating. iii)there was a strong indication of a complication occurring after the procedure. Thereafter, his failure to detect all these conditions led to delay in diagnosis all perforation of the bowel and has to lead a situation of avoidable delay which causes increased deterioration of the patient.”
• “In the case of Dr. Atul Mishra, no case of medical negligence can be established against him. Therefore, the Ethics Committee decided to drop the matter against Dr. Atul Mishra and exonerate him from the charges.”

Key Takeaways

• Medical practitioners have a duty to exercise a reasonable degree of skill and care in the treatment of their patients.
• Failure to detect and address post-operative complications promptly can constitutemedical negligence.
• The findings of the Medical Council of India (MCI) carry significant weight in cases involving medical negligence.
• Consumer Protection Act provides a remedy for patients who suffer due to medical negligence, allowing them to claim compensation for the harm suffered.
• In cases of medical negligence, the court will consider the expert opinions of doctors and the findings of the MCI.
• Doctors must be vigilant in monitoring patients post-surgery and promptly address any complications.
• The court emphasized the importance of considering all relevant evidence, including expert opinions and MCI reports, in cases of medical negligence.
• The court’s decision underscores the responsibility of medical practitioners to exercise due care and diligence in their practice.

Final Verdict

The Supreme Court allowed the appeals filed by the complainants. The court set aside the decision of the National Consumer Disputes Redressal Commission (NCDRC) and restored the findings of the State Consumer Disputes Redressal Commission (SCDRC), with modifications to the compensation amount. The court held that Dr. Gurmit Singh and Preet Surgical Centre & Maternity Hospital were negligent and deficient in service, and they were directed to pay compensation to the complainants.