Supreme Court overturns medical negligence ruling in Dr. Harish Kumar Khurana vs. Joginder Singh & Ors. (2021)

Date of the Judgment: 07 September 2021

Citation: 2021 INSC 593

Judges: Hemant Gupta, J., A.S. Bopanna, J.

Can every unfortunate death during a medical procedure be automatically attributed to medical negligence? The Supreme Court of India recently addressed this critical question in a case involving allegations of medical negligence against a doctor and a hospital. The court examined whether the National Consumer Disputes Redressal Commission (NCDRC) was correct in holding the appellants guilty of medical negligence, leading to the death of a patient. The bench comprised Justices Hemant Gupta and A.S. Bopanna, with the majority opinion authored by Justice A.S. Bopanna.

Case Background

The case revolves around Smt. Jasbeer Kaur, who was diagnosed with a kidney stone in her right kidney on 08.10.1996, and was advised surgery by Dr. R.K. Majumdar. She returned to the hospital on 03.12.1996, where it was found that her right kidney was severely damaged and her left kidney also had a stone. She was diagnosed with Hydronephrosis Grade IV with a renal stone in the right kidney and Hydronephrosis Grade II in the left kidney. She was again advised surgery.

Smt. Kaur was admitted on 06.12.1996 and declared fit for surgery. On 07.12.1996, Dr. H.K. Khurana explained that both kidneys could not be operated on simultaneously due to the severity of the damage. It was decided that the less affected left kidney would be operated on first. On 09.12.1996, an informed consent for high-risk surgery was obtained. The surgery on the left kidney was successful. By 12.12.1996, her condition improved, and a second surgery on the right kidney was considered. After tests, she was cleared for the second surgery.

The second surgery was scheduled for 16.12.1996. Dr. H.K. Khurana administered injections of Pentothal Sodium and Scolin. During the procedure, the patient’s condition deteriorated, her blood pressure fell, and she suffered a cardiac respiratory arrest. Despite efforts, she passed away on 23.12.1996.

Following the death, a dispute arose over unpaid medical bills. The husband of the deceased, who was a union leader, organized a demonstration at the hospital on 06.02.1997. This led to criminal charges against the hospital and a magisterial inquiry. The hospital filed a suit for recovery of medical bills on 13.08.1997. Subsequently, a criminal complaint was filed on 27.09.1997, followed by a complaint before the NCDRC on 06.12.1997, alleging medical negligence and seeking compensation.

Timeline:

Course of Proceedings

The NCDRC found the appellants guilty of medical negligence and directed them to pay Rs. 17,00,000 with 9% interest from the date of filing the complaint. The NCDRC concluded that the doctors did not exercise the required care in treating the patient. The NCDRC noted that the surgeon, Dr. Majumdar, had recorded that the patient had poor tolerance to anaesthesia, and despite this, the second operation was forced upon the patient. It was also noted that the hospital did not have a ventilator available and that consent for the second operation was not properly obtained. The NCDRC also relied on a magisterial inquiry report that indicated the absence of a paging system in the hospital, leading to delays in securing a physician.

The appellants, including the anaesthetist, the hospital, and the insurance company, appealed the NCDRC order to the Supreme Court, arguing that the NCDRC’s findings were based on assumptions and a misinterpretation of medical records. They contended that the cardiac arrest was an unforeseen event and that they had taken all necessary precautions.

Legal Framework

The Supreme Court referred to the legal principles governing medical negligence, particularly the test laid down in Jacob Mathew vs. State of Punjab and Anr. (2005) 6 SCC 1. This test states that negligence in diagnosis or treatment is established when a doctor fails to act with the ordinary skill expected of a doctor with ordinary care. The Court also noted that an accident during medical treatment has a broader meaning and includes unintended and unforeseen occurrences. Further, the court cited Martin F.D’Souza vs. Mohd. Ishfaq (2009) 3 SCC 1, which clarifies that a doctor cannot be held liable for medical negligence simply because a treatment or surgery has failed unless there is strong evidence of negligence.

The Court also discussed the principle of *res ipsa loquitur*, which means “the thing speaks for itself.” This principle applies when the negligence is so obvious that the complainant does not have to prove anything. However, the Court clarified that this principle should be applied cautiously in medical negligence cases. The Court also referred to the case of *V. Kishan Rao vs. Nikhil Super Speciality Hospital and Another (2010) 5 SCC 513*, which stated that the general directions given in *Martin F.D’Souza* to secure a medical report at a preliminary stage should not be treated as a binding precedent and must be confined to the particular facts of that case.

Arguments

Appellants’ Arguments:

• The appellants contended that the patient’s surgical recovery after the first operation was excellent, and the patient herself insisted on the second surgery.
• They argued that an informed consent was obtained from the patient’s husband, where the risk factor was recorded.
• The appellants stated that every untoward incident cannot be considered medical negligence.
• They highlighted the facilities available at the hospital and the care taken by the doctors.
• The anaesthetist, Dr. Khurana, clarified that the comment about poor tolerance to anaesthesia was not a major issue since the first operation was successful and uneventful.
• Dr. Khurana stated that he had administered anaesthesia to over 25,000 patients and had sufficient experience.
• They argued that the hospital had followed the necessary procedures and that the cardiac arrest was an unforeseen complication.

Respondents’ Arguments:

• The respondents argued that the observation on 14.12.1996, stating that the patient was insisting on the second surgery, was an insertion.
• They contended that the patient suffered a cardiac arrest immediately after the anaesthesia was administered.
• The respondents claimed that the hospital was negligent for not possessing a ventilator and that the Boyle’s apparatus was insufficient.
• They also argued that the hospital did not have a public address system or paging service, leading to a delay in securing a physician.
• The respondents argued that the second operation within a short duration was forced upon the patient, and that the doctors had not taken appropriate care despite the observation of poor tolerance to anaesthesia.

The respondents relied on *V. Kishan Rao vs. Nikhil Super Speciality Hospital and Another (2010) 5 SCC 513*, to argue that the principle of *res ipsa loquitur* should apply in this case, and the burden was on the appellants to prove they were not negligent. They also referred to *S.K. Jhunjhunwala vs. Dhanwanti Kaur and Another (2019) 2 SCC 282* to argue that there has to be a direct nexus between the improper performance of surgery and the ailment suffered by the patient, and *Nizam’s Institute of Medical Sciences vs. Prasanth S. Dhananka and Others (2009) 6 SCC 1* to highlight the broad principles under which medical negligence as a tort has to be evaluated.

Submissions Table

Issues Framed by the Supreme Court

The Supreme Court did not explicitly frame issues in a separate section. However, based on the judgment, the key issues that the court addressed were:

1. Whether the NCDRC was correct in holding the appellants guilty of medical negligence based on the available evidence.
2. Whether the observation of the surgeon regarding the patient’s poor tolerance to anaesthesia was adequately addressed by the anaesthetist before proceeding with the second surgery.
3. Whether the second surgery should have been undertaken within eight days of the first surgery.
4. Whether the hospital was negligent in not having a ventilator and a proper paging system.
5. Whether the consent for the second surgery was valid.
6. Whether the principle of *res ipsa loquitur* applies to the facts of the case.

Treatment of the Issue by the Court

Authorities

The Supreme Court considered the following authorities:

Judgment

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

How each authority was viewed by the Court?

• The Court relied on Jacob Mathew vs. State of Punjab and Anr. (2005) 6 SCC 1* to define the standard of care expected from a doctor.
• The Court used Martin F.D’Souza vs. Mohd. Ishfaq (2009) 3 SCC 1* to clarify that a doctor cannot be held liable simply because a treatment has failed, unless there is strong evidence of negligence.
• The Court referred to V. Kishan Rao vs. Nikhil Super Speciality Hospital and Another (2010) 5 SCC 513* to explain that the principle of *res ipsa loquitur* applies when negligence is evident, and that the need for expert evidence depends on the complexity of the case.
• The Court referred to S.K. Jhunjhunwala vs. Dhanwanti Kaur and Another (2019) 2 SCC 282* to highlight the need for a direct link between the alleged negligence and the harm suffered.
• The Court cited Nizam’s Institute of Medical Sciences vs. Prasanth S. Dhananka and Others (2009) 6 SCC 1* to underscore the broad principles for evaluating medical negligence as a tort.

What weighed in the mind of the Court?

The Supreme Court’s decision was primarily influenced by the lack of medical evidence supporting the claim of negligence. The court emphasized that the NCDRC’s conclusions were based on assumptions and a misinterpretation of medical records, rather than on concrete medical evidence or expert opinions. The court also highlighted that the anaesthetist had experience and that the first surgery was uneventful, which weighed against the claims of negligence.

Fact:Law Ratio

The court’s reasoning was heavily influenced by the legal principles of medical negligence, particularly the need for concrete evidence and the limitations of the *res ipsa loquitur* principle. The court’s analysis of the facts was primarily to determine whether the legal requirements for establishing negligence were met.

Logical Reasoning:

The court considered alternative interpretations, such as the argument that the hospital’s lack of a ventilator and paging system contributed to the patient’s death. However, the court rejected these interpretations because there was no medical evidence to establish a causal link between these factors and the patient’s death. The court emphasized the importance of medical evidence in determining medical negligence and the limitations of relying on assumptions or general perceptions.

The Supreme Court ultimately concluded that the NCDRC’s findings were not sustainable due to the lack of medical evidence supporting the claim of negligence. The court emphasized that every death during a medical procedure does not automatically imply negligence, and that the burden of proof lies with the complainant to demonstrate negligence through concrete evidence.

The court’s decision was based on the following reasons:

• There was no medical evidence to indicate negligence on the part of the doctors.
• The anaesthetist was experienced, and the first surgery was uneventful.
• The decision to proceed with the second surgery was a medical one, and there was no expert opinion to suggest it was incorrect.
• The lack of a ventilator and paging system did not directly cause the patient’s death.
• Valid consent was obtained for the second surgery.
• The principle of *res ipsa loquitur* did not apply in this case.

The court quoted the following from the NCDRC’s order:

“We are surprised to note that the treating doctor after recording that the patient had poor tolerance to anaesthesia has tried to defend his actionduring the course of arguments, which we do not appreciate. It is also surprising to note that the treating doctor has in his affidavit tried to defend the absence of ventilator in the hospital. The treating doctor has also tried to defend the absence of public address system or paging system in the hospital. The hospital does not have any explanation for not having a ventilator and paging system in the hospital. The treating doctor has in his affidavit also stated that the consent for the second operation was obtained from the husband of the patient on 14.12.1996, however, this does not appear to be the case. It appears that the consent for the second operation was obtained from the husband of the patient on 09.12.1996 and the same is an insertion. It is also to be noted that the patient was forced to undergo the second operation within a short duration of eight days. In view of the above, we are of the considered view that the appellants have not taken proper care and caution while treating the patient and are therefore, guilty of medical negligence.”

The Supreme Court observed that the NCDRC had made these observations without any medical evidence to support them. The court noted that the NCDRC had based its conclusions on assumptions and a misinterpretation of medical records.

Conclusion

The Supreme Court concluded that the NCDRC’s order holding the appellants guilty of medical negligence was unsustainable. The court emphasized that there was no medical evidence to support the claim of negligence, and that the NCDRC’s conclusions were based on assumptions and a misinterpretation of medical records.

Final Order:

The Supreme Court set aside the order passed by the National Consumer Disputes Redressal Commission (NCDRC) and allowed the appeal. The court held that the appellants were not guilty of medical negligence.

Implications:

• The judgment reinforces the need for concrete medical evidence to establish medical negligence.
• It clarifies that the failure of a medical procedure does not automatically imply negligence.
• It emphasizes the importance of expert opinions in medical negligence cases.
• It underscores the limitations of relying on the principle of *res ipsa loquitur* in medical negligence cases.
• It sets a precedent for future cases involving allegations of medical negligence, highlighting the need for a thorough and evidence-based approach.

This judgment serves as a significant reminder that medical negligence must be proven with substantial evidence and not merely assumed based on an unfortunate outcome. It reinforces the importance of adhering to established legal principles and the need for expert medical opinions in such cases.