Mrs. Kalyani Rajan Vs. Indraprastha Apollo Hospital & ors.

Appellant:                              Mrs Kalyani Rajan 

Respondents:                        Indraprastha Apollo Hospital, Dr. Ravi Bhatia

Date of Judgement:             17/10/2023 

Bench/Judge:                        A. S. BOPANNA and PRASHANT KUMAR MISHRA, JJ

Court:                                     The Supreme Court of India, New Delhi

Legal Provisions:                  Law of Torts, Principle of Res Ipsa Loquitur, Consumer Protection Act, 1986

Case No.:                               Civil Appeal No. 10347 of 2010

FACTS

  1. Mrs. Kalyani Rajan, wife of Mr. Sankar Rajan filed a Complaint before the Hon’ble National Consumer Dispute Redressal Commission, against Indraprastha Apollo Hospital and Dr. Ravi Bhatia for causing negligence in taking due care of her husband post- surgery.
  2. Mr. Sankar Rajan was suffering from Chiari Malformations (Type II) with Hydrocephalous. He had consulted, Dr. Ravi who is a Senior Consultant, Department of Neurosurgery of Indraprastha Apollo Hospital on 21.10.1998 and was advised to get admitted to the Hospital by Dr. Ravi, where the surgery would be performed.
  3. Mr. Sankar Rajan, on the advice of Dr. Ravi, got himself admitted to the Hospital on 29.10.1998.
  4. Thereafter, after conducting the preoperative examinations, Dr. Ravi conducted the operation on the Mr. Sankar Rajan. Then he was shifted to a private room at around 4:15 p.m.
  5. Further, the Doctors visited Mr. Rajan at around 4.30 p.m, wherein he informed them about the pain in the neck region, which seemed to have transferred downward lower than the region where the pain used to occur prior to the operation.
  6. Thereafter, at 6:30 p.m. due to the increase in the pain, Mr. Rajan was given an intravenous pain reliever but the pain increased along with severe sweat spells.
  7. Later, Mrs. Rajan called Dr. Ravi at his residential phone number but he was unavailable. Again, at 11:00 p.m. Mrs. Kalyani Rajan called and spoke to Dr. Ravi at his residence, and informed him that her husband had suffered a heart attack around 11:00 p.m.
  8. Mr. Rajan was declared brain dead on 31.10.1998 and was kept on life support till  06.11.1998.
  9. Mrs. Kalyani Rajan, filed a Complaint against the Hospital and Dr. Ravi before the National Consumer Dispute Redressal Commission under Section 2 (c)(iii) of the Consumer Protection Act, 1986 for the reason that Mr. Rajan was not attended to by any doctor from the neurosurgery team who had operated on him after he was shifted into the private room.
  10. Her complaint was rejected by an order passed by the National Consumer Disputes Redressal Commission1 dated 03.08.2010. Then the appeal was directed to the Supreme Court of India against the order given by the NCDRC.

ISSUES

  1. Whether the Indraprastha Apollo Hospital and Dr. Ravi Bhatia have committed negligence by failing to provide necessary postoperative medical treatment to Mr. Rajan.
  2. Whether the Commission (NCDRC) has committed any illegality while rejecting the complaint filed by the deceased’s wife.

CONTENTIONS

            ARGUMENTS FROM APPELLANT (Mrs. Kalyani Rajan):

  1. Shri Nikhil Nayyar, learned senior counsel appearing for the appellant submits that the deceased died due to cardiac arrest, albeit, admittedly, the deceased had no cardiac problems. He would further submit that at the time of admission the deceased was informed that after the surgery he would be shifted to the ICU. However, he was shifted from the recovery room directly to a private room and not to the ICU.
  2. In respect of lack of care, he submits that, Dr. Brahm Prakash & Dr. S. Tyagi, visited the room at around 4.30 p.m. and the deceased mentioned about pain in the neck region. The said complaint by the deceased was dismissed as post operative symptom. The said visit was the only visit by Respondent-2 and other specialists post the surgery in the private room till the deceased lost consciousness. Since the pain was not reducing, the Duty Doctor spoke to Dr. Tyagi around 7.15 p.m. on telephone on the basis which Nimulid was prescribed by Dr. Tyagi. Thereafter, Dr. Tyagi had a telephonic conversation with the deceased wherein he was informed that Nimulid did give some temporary relief, basis which he concluded that the symptoms of pain felt by the patient were clearly normal post operative reaction.
  3. It is submitted that the patient had an episode of Ventricular Tachycardia (‘VT’) and Respondent-2 in his admission has stated that VT is not his area of expertise and in such cases, patient should have been referred to the appropriate doctor. However, this was not done and no consultant/specialist with the relevant expertise was available to attend to the medical needs of the deceased.
  4. Apropos the findings of the impugned order, the appellant herein refutes the same and submits that they are contrary to the facts on record which establishes negligence of the respondents in the post operative care of the deceased.
  5. Learned senior counsel further states that the Commission has not appreciated that the present case reflects clear example of negligence due to absence of care. In support of this, he states that there was : 
  1. Complete absence of senior doctor, surgeon/specialist to respond to patient’s distress call from the time the patient was shifted to the room/ward till the time he became unconscious and; 
  2. Absence of investigation of pain to diagnose the cause.

Arguments on behalf of Respondent No. 1(Hospital):

  1. Dr. Lalit Bhasin, learned counsel appearing for Respondent no. 1 would submit that Respondent no. 1 is one of the best hospitals equipped with latest medical equipments and the patient was looked after by Dr. Ravi Bhatia of international repute, who was formerly Professor and Head of the Neuro-Surgery and he was assisted by Dr. Brahm Prakash, senior Neurosurgeon. It was also submitted that patient had made excellent recovery after neurosurgery and there were no post operative complications, therefore, he was shifted to recovery room and thereafter to private room.
  2. Learned counsel has drawn our attention to the records of the hospital containing pre and post operative history of the patient. Thus, according to learned counsel, there is no negligence on the part of the hospital or the treating doctors.
  3. Learned counsel for Respondent no. 1 refutes the contentions of the Appellant and submits that in view of the findings of the Commission and the dicta of this Court in Bombay Hospital & Medical Research Centre v. Asha Jaiswal, the present appeal is liable to be dismissed.

            Arguments on behalf of Respondent No. 2 (Dr. Bhatia):

  1. Ms. Meenakshi Arora, learned senior counsel for Respondent no. 2 adopts the submissions advanced on behalf of Respondent no. 1 apropos findings of the Commission in the impugned order as well as the dicta of this Court in Bombay Hospital.
  2. Additionally, Respondent no. 2 submits that it was explained to the Appellant and the deceased that the patient would be examined in the recovery room first and thereafter as per standard practice followed by the hospital, all patients who do not show signs of complications in the Recovery Room and have no pre-operative medical problems are shifted to their ward/room. In case the patient develops some post-operative complications that requires round the clock care and observation, he/she would be transferred to the Neurology Intensive Care Unit. Respondent no. 2 also submits that the deceased had regained full consciousness at the time when he had been moved from the Operation Theatre to the Recovery Room. Also, less than half the numbers of neurosurgical patients operated upon are moved from the OT to Recovery Room and then to Neurosurgery ICU. In support of the same, he has submitted data of Respondent no. 1 apropos the neurosurgeries conducted and number of patients transferred to Neuro ICU thereafter.
  3. Learned senior counsel further submits that Dr. Brahm Prakash of the Neuro-Sciences Department at the Respondent No. 1 met the deceased, and no complaint was made by the patient at that time. Similarly, at about 5 p.m. he along with Dr. Tyagi met with the deceased and examined him. The deceased at that time complained of only a mild neck pain, which is normal after an operation on the cervical (neck) region. Thereafter, he left the hospital for his premises and submits that since the time he left i.e., around 5,30 p.m. till the time he received a phone call from the Appellant at about 11.15 p.m. about the condition of the deceased, he had not received any calls on his mobile phone or his landline, nor was any message left for him at his residence.
  4. Learned senior counsel categorically refutes the contentions of the Appellant and submits that the impugned order suffers from no infirmity warranting interference by this Court and is liable to be accordingly dismissed.

RATIONALE:

COMMISSION’S ANALYSIS:

The Commission concluded that the Appellant failed to provide compelling evidence or material on record linking the deceased’s heart attack to the operation in question or to any negligence in post-operative care. Additionally, the Commission noted that the deceased had no documented history of diabetes, hypertension, or heart problems, as asserted by Respondent No. 2 in their testimony. Based on these findings, the Commission determined that there was no indication of medical negligence on the part of the Respondents. The principle of Res Ipsa Loquitur, which presumes negligence based on the circumstances of the case, was deemed inapplicable to the facts presented here. Dissatisfied with the Commission’s decision dated August 2010, the Appellant filed Civil Appeal No. 10347 of 2010 in the Supreme Court.

Supreme Court’s Analysis:

The Supreme Court, in its order dated October 17, 2023, emphasized the central issue of determining whether the Respondents were negligent in providing proper post-operative medical care to the patient, and consequently, whether the Commission erred in dismissing the Appellant’s complaint. It noted that the Appellant did not dispute the diagnosis or recommended surgical treatment provided by Respondent No. 2; rather, the focus of the case was on the alleged lack of adequate post-operative care. Specifically, the Appellant argued that the deceased should have been transferred to the Intensive Care Unit (ICU) instead of being placed in a private room.

According to standard practice, patients without post or pre-operative complications are typically sent to the ward or room. The symptoms exhibited by the deceased after being discharged from the Operation Theatre were not indicative of an impending cardiac arrest, especially considering the absence of known heart ailments. Thus, the Respondents couldn’t have foreseen the development of a cardiac issue shortly after surgery.

The Court referenced the case of Jacob Mathew vs. State of Punjab and Anr. which outlines the criteria for determining medical negligence. It stated that a medical professional can be deemed negligent if they lack the required skill or fail to apply their skills competently. However, the standard of judgment should be that of an ordinary competent person in the profession.

“A professional may be held liable for negligence on one of the two findings: either he was not possessed of the requisite skill which he professed to have possessed, or, he did not exercise, with reasonable competence in the given case, the skill which he did possess. The standard to be applied for judging, whether the person charged has been negligent or not, would be that of an ordinary competent person exercising ordinary skill in that profession. It is not possible for every professional to possess the highest level of expertise or skills in that branch which he practices. A highly skilled professional may be possessed of better qualities, but that cannot be made the basis or the yardstick for judging the performance of the professional proceeded against on indictment of negligence.

Regarding the allegation that the deceased was not attended to by any doctor from the neurosurgery team until he suffered a cardiac arrest at 11:00 p.m., the Court found evidence indicating otherwise. Dr. Brahm Prakash, Dr. Ravi Bhatia, and Dr. Tyagi attended to the patient after he was transferred to the private room. The patient complained of neck pain, which was treated accordingly. Subsequently, when the patient exhibited symptoms such as sweating and dizziness, the attending doctor deemed them as normal post-operative reactions.

In its consideration of the case of Martin F. D’Souza v. Mohd. Ishfaq ,the Supreme Court made a notable observation regarding the application of the Doctrine of Res Ipsa Loquitur in cases of alleged medical negligence. The Court highlighted that doctors cannot automatically be deemed liable for medical negligence simply because a patient’s treatment did not yield the desired outcome or a surgical procedure failed. It expressed concern over the tendency to blame doctors when patients experience adverse outcomes, such as death or mishaps. 

“Simply because a Patient has not favourably responded to a treatment given by a doctor or a surgery has failed, the doctor cannot be held straightaway liable for medical negligence by applying the doctrine of res ipsa loquitur. No sensible professional would intentionally commit an act or omission which would result in harm or injury to the Patient since the professional reputation of the professional would be at stake. A single failure may cost him dear in his lapse. When a Patient dies or suffers some mishap, there is a tendency to blame the doctor for this. Things have gone wrong and, therefore, somebody must be punished for it. However, it is well known that even the best professionals, what to say of the average professional, sometimes have failures. A lawyer cannot win every case in his professional career but surely he cannot be penalised for losing a case provided he appeared in it and made his submissions.

In C.P. Sreekumar (Dr.), MS (Ortho) v. S. Ramanujam, this Court held that the Commission ought not to presume that the allegations in the complaint are inviolable truth even though they remained unsupported by any evidence.

The Court rejected the application of the Doctrine of Res Ipsa Loquitur, stating that it requires strong incriminating circumstantial or documentary evidence to establish negligence. It held that there was no mistake or negligent diagnosis by Respondent No. 2, especially considering the absence of a history of diabetes, hypertension, or cardiac problems in the patient. Thus, the Court found no grounds to hold the Respondents liable for negligence in this case.

DEFECTS OF LAW

The complainant has never questioned the diagnosis and recommended surgical treatment given to him by 12 respondent no. 2-Dr. Bhatia. It is not the case of the complainant that Dr. Bhatia was negligent in performing the Neurosurgery. Thus, the entire case of the complainant was about lack of proper post-operative medical care. On this score, the allegation is that the patient should have been shifted to ICU instead of shifting him to a private room. The material available on the record demonstrates that as per the standard practice, all patients who show no signs of complications in the recovery room and have no post or preoperative complications are sent to their rooms. According to the figures submitted by the respondents, during the months of September to November 1998, out of 166 neurosurgeries, only 68 patients were sent to the ICU from the recovery room in the hospital of respondent no. 1. The rest were sent back to their wards in accordance with standard procedure. It is the stand of respondent no. 2 that there exists no link or interconnection between post-operative treatment/care and the cardiac arrest suffered by the deceased. The symptoms, which emerged after the deceased was discharged from the Operation Theatre, were not the symptoms, which typically precede a cardiac arrest. Since, the deceased did not have any known or identifiable 13 heart ailments, it was impossible for the respondents to have prior knowledge that the patient may develop cardiac problem after few hours of the successful surgery. The symptoms, including dizziness, sweating, and pain in the neck area, experienced by the deceased post-surgery, could not be treated as post-surgery reactions. The patient would have been shifted to the ICU immediately, if serious complications would have arisen after the surgery, therefore, in the absence of complications in the surgery or soon thereafter, the patient was not required to be shifted to ICU and there is no negligence on this count by either of the respondents.

INFERENCE

Based on the foregoing analysis, the Apex Court concluded that the Appellant did not substantiate allegations of negligence against the Respondents concerning post-operative care. The Court found that the Commission’s findings on this matter were legally sound and not perverse. Consequently, the Appeal was dismissed.

Happy Kushwah

The ICFAI University, Jaipur