Supreme Court Holds Surgeon Negligent for Operating with Low Platelet Count: Nand Kishore Prasad vs. Dr. Mohib Hamidi (2019)

Introduction

Date of the Judgment: May 10, 2019

Citation: 2019 INSC 460

Judges: Dr. Dhananjaya Y. Chandrachud, J. and Hemant Gupta, J.

Can a doctor be held liable for medical negligence if they proceed with surgery despite a patient having a dangerously low platelet count? The Supreme Court of India addressed this critical question in a case involving the death of a 15-year-old boy. The court examined whether the operating surgeon acted negligently by performing surgery when the patient’s platelet count was significantly below normal, ultimately holding the surgeon liable for medical negligence. This judgment clarifies the responsibilities of medical professionals in critical situations.

Case Background

Sanjay Kumar, a 15-year-old boy, experienced abdominal pain, fever, and hemorrhaging in both eyes. On November 8, 1995, he was initially seen by Dr. Arun Tiwari, who prescribed some tests and medicines. After reviewing the blood reports, Dr. Tiwari referred Sanjay to Kurji Holy Family Hospital on November 10, 1995. Upon admission at 8:00 PM, the hospital recorded Sanjay’s symptoms as fever, abdominal pain, and hemorrhaging in both eyes for the past five days.

On November 11, 1995, at 11:15 AM, Sanjay underwent surgery. His platelet count before the surgery was 35,000 per cubic millimeter (cu.mm). He received two units of blood before the surgery and another two units after. Despite attempts to control the bleeding, Sanjay’s relatives discharged him from Kurji Holy Family Hospital on November 13, 1995, at 2:00 PM. The same day, he was admitted to Patna Medical College and Hospital (PMCH), where he died on November 16, 1995.

Timeline:

Course of Proceedings

The State Consumer Disputes Redressal Commission (SCDRC) found the operating surgeon negligent for performing surgery when the patient’s platelet count was critically low (35,000 cu.mm, while the normal range is 1.5 to 4 lakhs cu.mm). The SCDRC awarded a total compensation of Rs. 6,00,000/- to be paid by the Kurji Holy Family Hospital (Rs. 4,00,000) and the operating surgeon (Rs. 2,00,000), along with interest, medical expenses, and litigation costs.

On appeal, the National Consumer Disputes Redressal Commission (NCDRC) absolved the operating surgeon of the liability, stating that the hospital’s compensation was sufficient. The NCDRC, while acknowledging a minor degree of negligence on the part of the surgeon, did not uphold the compensation awarded against him by the SCDRC.

Legal Framework

The case was brought under the Consumer Protection Act, 1986. The core issue revolves around medical negligence, specifically whether the operating surgeon acted unreasonably by performing surgery with a critically low platelet count.

The Supreme Court referred to its previous judgment in Arun Kumar Manglik v. Chirayu Medical Health and Medicare Private Ltd. [2019 SCC OnLine SC 197], which stated that while there can be different approaches to treatment, a medical professional must ensure that their course of treatment is not unreasonable. The court emphasized that the threshold to prove unreasonableness is set with due regard to the risks associated with medical treatment.

The Court also cited Kusum Sharma and Others v. Batra Hospital and Medical Research Centre and Others [(2010) 3 SCC 480], which held that doctors must take chances in complicated cases, but they should be held liable for negligence to ensure safer practices and prevent future negligence.

Arguments

Appellant’s Arguments:

• The appellant argued that the operating surgeon was negligent for operating on Sanjay despite his low platelet count of 35,000 cu.mm, which is far below the normal range of 1.5 to 4 lakhs cu.mm.
• The appellant relied on the affidavit of Dr. Hare Ram Singh, who stated that operating on a patient with such a low platelet count was a significant error and a clear case of extreme negligence.
• The appellant contended that the surgery was not an immediate necessity to save the patient’s life, given his low platelet count.
• The appellant sought enhanced compensation, citing V. Krishnakumar v. State of Tamil Nadu and Others [(2015) 9 SCC 388], which emphasized the principle of restitutio in integrum.

Respondents’ Arguments:

• The respondents argued that the patient was in a critical condition upon admission, with hemorrhaging in both eyes for five days.
• They submitted that the surgeon’s decision to operate was a bona fide attempt to save the patient’s life by removing roundworms and transfusing blood.
• The respondents contended that the affidavit of Dr. Hare Ram Singh did not provide a complete picture, as it did not include the patient’s condition at the time of admission to the hospital.
• The respondents argued that the surgeon’s actions were not negligent but a necessary intervention in a critical situation.

Submissions by Parties

Issues Framed by the Supreme Court

The Supreme Court considered the following issue:

1. Whether the operating surgeon was negligent in performing the surgery on the patient with a low platelet count of 35,000 cu.mm.

Treatment of the Issue by the Court

Authorities

Cases:

• Arun Kumar Manglik v. Chirayu Medical Health and Medicare Private Ltd. [2019 SCC OnLine SC 197] – The Supreme Court referred to this case to emphasize that medical professionals must ensure their treatment is not unreasonable.
• Kusum Sharma and Others v. Batra Hospital and Medical Research Centre and Others [(2010) 3 SCC 480] – This case was cited to highlight that doctors must take chances in complicated cases but are liable for negligence.
• V. Krishnakumar v. State of Tamil Nadu and Others [(2015) 9 SCC 388] – The court referred to this case to emphasize the principle of restitutio in integrum, which aims to restore the aggrieved party to the position they would have been in had the wrong not occurred.
• National Insurance Company Limited v. Pranay Sethi and Others [(2017) 16 SCC 680]– This case was cited to lay down the parameters for granting compensation, emphasizing fairness, reasonableness, and equitability.
• Malay Kumar Ganguly v. Sukumar Mukherjee [(2009) 9 SCC 221] – This case was referred to for the principle of restitutio in integrum.
• Balram Prasad v. Kunal Saha [(2014) 1 SCC 384]– This case was referred to for the principle of restitutio in integrum.
• Sarla Verma v. Delhi Transport Corporation [(2009) 6 SCC 121] – This case was referred to for the multiplier method in determining compensation.
• Reshma Kumari v. Madan Mohan [(2013) 9 SCC 65] – This case was referred to for the multiplier method in determining compensation.
• Livingstone v. Rawyards Coal Co [(1880) LR 5 AC 25 (HL)] – This case was referred to for the principle of restitutio in integrum.

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?

• Arun Kumar Manglik v. Chirayu Medical Health and Medicare Private Ltd. [2019 SCC OnLine SC 197]: The Court used this case to emphasize that medical professionals must ensure their treatment is not unreasonable.
• Kusum Sharma and Others v. Batra Hospital and Medical Research Centre and Others [(2010) 3 SCC 480]: The Court cited this case to highlight that while doctors must take chances in complicated cases, they are liable for negligence.
• V. Krishnakumar v. State of Tamil Nadu and Others [(2015) 9 SCC 388]: The Court referred to this case to emphasize the principle of restitutio in integrum for compensation.
• National Insurance Company Limited v. Pranay Sethi and Others [(2017) 16 SCC 680]: The Court used this case to lay down the parameters for granting fair and equitable compensation.
• Malay Kumar Ganguly v. Sukumar Mukherjee [(2009) 9 SCC 221]: The Court referred to this case for the principle of restitutio in integrum.
• Balram Prasad v. Kunal Saha [(2014) 1 SCC 384]: The Court referred to this case for the principle of restitutio in integrum.
• Sarla Verma v. Delhi Transport Corporation [(2009) 6 SCC 121]: The Court referred to this case for the multiplier method in determining compensation.
• Reshma Kumari v. Madan Mohan [(2013) 9 SCC 65]: The Court referred to this case for the multiplier method in determining compensation.
• Livingstone v. Rawyards Coal Co [(1880) LR 5 AC 25 (HL)]: The Court referred to this case for the principle of restitutio in integrum.

What weighed in the mind of the Court?

The Court’s decision was primarily influenced by the lack of evidence that the surgery was the only option to save the patient’s life, especially given the critically low platelet count. The Court emphasized that while medical professionals have the discretion to choose a course of treatment, that treatment must not be unreasonable. The Court found that the surgeon’s decision to operate, without any evidence of immediate necessity, was unreasonable. The Court also relied on the principle that doctors are liable for negligence to ensure safer practices and prevent future negligence.

Fact:Law Ratio

The court’s reasoning was a mix of factual analysis and legal principles. The factual aspect was the patient’s low platelet count and the lack of evidence that the surgery was the only option. The legal aspect was the principle that medical professionals are liable for negligence, and their treatment must not be unreasonable.

The Court did not explore alternative interpretations. It focused on the factual evidence of the low platelet count and the absence of any evidence that the surgery was the only life-saving option. The Court then applied the legal principle that medical treatment must not be unreasonable, concluding that the surgeon’s decision was negligent.

The Supreme Court held that the operating surgeon was negligent in performing surgery on the patient with a low platelet count of 35,000 cu.mm. The Court set aside the NCDRC’s decision, which had absolved the surgeon of liability. The Court found that the surgeon’s decision to operate was unreasonable in the absence of evidence that it was the only life-saving option.

The reasons for the decision were:

• The patient’s platelet count was critically low (35,000 cu.mm).
• There was no evidence that the surgery was the only life-saving option.
• The surgeon’s decision to operate was unreasonable under the circumstances.
• Medical professionals must ensure their treatment is not unreasonable.

“In the practice of medicine, there could be varying approaches to treatment. There can be a genuine difference of opinion. However, while adopting a course of treatment, the medical professional must ensure that it is not unreasonable.”

“The professional should be held liable for his act or omission, if negligent; is to make life safer and to eliminate the possibility of recurrence of negligence in future.”

“In the absence of any evidence that the surgery was the only option even with low blood platelets, the finding of negligence of the operating surgeon cannot be ignored.”

There were no dissenting opinions. The judgment was delivered by a bench of two judges, both of whom agreed on the decision.

The Court’s reasoning was based on a combination of factual analysis and legal principles. The Court found the surgeon’s decision to be unreasonable and negligent. The Court’s decision has implications for future cases involving medical negligence, particularly those involving surgical decisions in critical situations.

The decision did not introduce any new doctrines or legal principles. It reaffirmed the existing principle that medical professionals must ensure their treatment is not unreasonable and that they are liable for negligence.

Key Takeaways

• Doctors must carefully evaluate the patient’s condition before proceeding with surgery, especially in cases with critical parameters like low platelet counts.
• Medical professionals can be held liable for negligence if their treatment decisions are found to be unreasonable.
• The principle of restitutio in integrum is crucial in awarding compensation in cases of medical negligence.
• The judgment reinforces the importance of ensuring safer medical practices and preventing future negligence.

The judgment is likely to have a significant impact on future medical negligence cases, particularly those involving surgical decisions in critical situations. It emphasizes the need for doctors to make prudent decisions based on evidence and not to proceed with risky procedures without sufficient justification.

Directions

The Supreme Court directed that the entire compensation amount of Rs. 6,00,000/- be paid by the hospital, along with interest at 6% per annum from the date of the SCDRC’s order (November 12, 2014).

Development of Law

The ratio decidendi of this case is that a surgeon is negligent if they operate on a patient with a critically low platelet count without any evidence that surgery was the only life-saving option. This case reinforces the existing legal position that medical professionals must ensure their treatment is not unreasonable and that they are liable for negligence. There is no change in the previous position of the law, but the judgement clarifies the application of the principle of medical negligence in surgical cases.

Conclusion

The Supreme Court’s judgment in Nand Kishore Prasad vs. Dr. Mohib Hamidi & Others held the operating surgeon liable for medical negligence for performing surgery on a patient with a critically low platelet count. The Court emphasized that medical professionals must ensure their treatment is reasonable and that they are liable for negligence. The Court directed the hospital to pay the entire compensation amount, along with interest. This judgment reinforces the importance of prudent decision-making by doctors and the need to ensure safer medical practices.