Supreme Court Holds Nursing Home Liable for Lack of ICU in Medical Negligence Case: Bijoy Sinha Roy (D) vs. Biswanath Das & Ors. (2017) INSC 739 (30 August 2017)

Date of the Judgment: 30 August 2017

Citation: (2017) INSC 739

Judges: Adarsh Kumar Goel, J. and Uday Umesh Lalit, J.

Can a hospital be held liable for medical negligence if it performs surgery without adequate post-operative care facilities? The Supreme Court of India addressed this critical question in a case concerning the death of a patient following a hysterectomy. The Court examined whether the choice of a nursing home lacking an Intensive Care Unit (ICU) constituted medical negligence, especially when the need for such facilities was foreseeable. This case highlights the importance of adequate medical infrastructure and its impact on patient safety.

Case Background

The case revolves around the death of Bijoy Sinha Roy, who had been suffering from menstrual problems since June 1993. After consulting with Dr. Bishwanath Das, a gynecologist, she was diagnosed with multiple fibroids in her uterus and was advised to undergo a hysterectomy.

Following severe bleeding, she was admitted to Ashutosh Nursing Home for an emergency hysterectomy on December 1, 1993. She also had high blood pressure and anemia. The surgery was performed at 8:45 AM, but she did not regain consciousness. The nursing home lacked an ICU, and she was transferred to Repose Nursing Home and then to SSKM Hospital, where she died on January 17, 1994.

Timeline

Course of Proceedings

The appellant, Bijoy Sinha Roy’s husband, filed a complaint before the State Consumer Disputes Redressal Commission on June 16, 1994, alleging medical negligence. The State Commission ruled in favor of the appellant, finding that the surgery was performed without controlling the patient’s blood pressure and hemoglobin levels. The State Commission also noted that the surgery was conducted in a nursing home without ICU facilities, which was a critical oversight. The State Commission awarded compensation to the appellant.

The opposite parties, the doctors and the nursing home, appealed to the National Consumer Disputes Redressal Commission (NCDRC). The NCDRC reversed the State Commission’s order on September 12, 2007, stating that the doctors had followed acceptable medical practices and that there was no medical negligence. The NCDRC dismissed the complaint.

Legal Framework

The Supreme Court considered the definition of negligence in the context of medical practice. Negligence is defined as the breach of a duty caused by the omission to do something a reasonable person would do, or doing something a prudent person would not do. The Court referred to the principles laid down in *Jacob Mathew v. State of Punjab (2005) 6 SCC 1*, which held that a doctor is not liable for negligence merely because a better alternative course was available, as long as the doctor followed a practice acceptable to the medical profession of the day.

The Court also noted that the degree of negligence differs in civil and criminal law. In criminal law, a higher degree of negligence and the element of *mens rea* (guilty mind) may be required. The principle of *res ipsa loquitur* (the thing speaks for itself) has limited application in criminal negligence cases.

The Consumer Protection Act, 1986, was also considered, with the Court emphasizing its purpose of providing speedy remedies to consumers. The Court noted that the provisions of the Act are in addition to, and not in derogation of, any other law.

Arguments

The appellant argued that the doctors were negligent in two aspects:

• Firstly, the decision to perform surgery without first controlling the patient’s blood pressure and hemoglobin levels constituted medical negligence. The surgery was not an emergency and was conducted six months after the initial diagnosis.
• Secondly, the decision to perform surgery at a nursing home lacking ICU facilities, given the foreseeable complications, was also negligent.

The opposite parties contended that:

• The surgeon was entitled to make a choice and take the risk in the given situation. If it was not possible to stop the bleeding without performing the surgery, the surgeon rightly decided to do so. This decision cannot be held to be medical negligence.
• No specific reply was given regarding the forcibility of risk in performing surgery at a nursing home which did not have ICU even when better places were available nearby.

The appellant emphasized that the nursing home’s lack of ICU facilities was a significant factor contributing to the patient’s death. They argued that the nursing home should have had the necessary infrastructure to handle post-operative emergencies.

The opposite parties argued that the medical literature supported their decision to proceed with the surgery despite the patient’s condition. They also stated that the procedure was not elective as the deceased was having severe bleeding.

Issues Framed by the Supreme Court

The Supreme Court framed the following issues for consideration:

1. Whether the National Commission applied the right test for holding that there was no medical negligence in the decision of the surgeon to perform surgery.
2. Whether the choice of nursing home to perform surgery amounted to negligence as the requirement of ICU was a clear forcibility and centers with ICU were available nearby.

Treatment of the Issue by the Court

Authorities

The Court considered the following authorities:

Judgment

The Court considered the authorities as follows:

• *Jacob Mathew v. State of Punjab (2005) 6 SCC 1*: The Court relied on this case to define medical negligence and to state that a doctor cannot be held liable if they followed an acceptable medical practice.
• *Martin F.D’Souza versus Mohd. Ishfaq (2009) 3 SCC 1*: The Court referred to this case to highlight that uncalled for proceedings for medical negligence can have adverse impact on access to health.
• *V. Krishan Rao versus Nikhil Super Speciality Hospital (2010) 5 SCC 513*: The Court referred to this case to highlight that directions for mandatory expert opinion before consumer fora was inconsistent with the binding judgment in Jacob Mathew (supra).

What weighed in the mind of the Court?

The Court was primarily concerned with the fact that the nursing home did not have an ICU, which was a foreseeable requirement for post-operative care. The Court noted that neither the State Commission nor the National Commission had adequately addressed this issue. The Court emphasized that while the decision to perform surgery might not be negligent in itself, the choice of a facility without an ICU was a critical oversight.

The Court stated that “the operation should not have been performed at a nursing home which did not have the ICU when it could be reasonably foreseen that without ICU there was post operative risk to the life of the patient.”

The Court also noted, “The very object of setting up Consumer Fora was to provide speedy remedy to a consumer.”

The Court further observed that, “the provisions of the Act are in addition to and not in derogation of any other law.”

The Court did not find any majority or minority opinion.

Key Takeaways

• Hospitals and nursing homes must ensure they have adequate facilities, including ICUs, for post-operative care, especially when foreseeable complications exist.
• The choice of medical facility is a critical factor in determining medical negligence, not just the medical procedure itself.
• Consumer Fora are expected to provide speedy remedies to consumers, and delays in justice defeat the purpose of the Consumer Protection Act.
• The Court has emphasized the need to use ADR mechanisms to resolve disputes.

Directions

The Supreme Court directed the opposite party No. 1 to pay a sum of Rs. 5 lakh to the heirs of the appellant without any interest. The amount was to be deposited with the State Commission within 3 months for disbursement to the appellants. If the deposit was made beyond 3 months, the amount would carry an interest of 12% per annum.

The Court also requested the National Commission to consider monitoring mechanisms for speedy disposal of cases and to consider the use of ADR mechanisms.

Development of Law

The ratio decidendi of this case is that a medical facility can be held liable for medical negligence if it performs surgery without having the necessary infrastructure, such as an ICU, when the need for such infrastructure is foreseeable. This case clarifies that medical negligence is not just about the medical procedure itself, but also about the choice of medical facility and its ability to provide adequate post-operative care.

Conclusion

The Supreme Court’s decision in *Bijoy Sinha Roy (D) vs. Biswanath Das & Ors.* highlights the responsibility of medical facilities to ensure they have adequate infrastructure to handle post-operative emergencies. While the Court agreed that the decision to perform surgery was not in itself negligent, it held the nursing home liable for not having an ICU. This judgment underscores the importance of patient safety and the need for medical facilities to provide comprehensive care. The Court also emphasized the importance of speedy justice in consumer disputes and the use of ADR mechanisms.