Full Judgment Text
NONREPORTABLE
IN THE SUPREME COURT OF INDIA
CIVIL APPELLATE JURISDICTION
CIVIL APPEAL NO.7380 OF 2009
Dr. Harish Kumar Khurana .…Appellant(s)
Versus
Joginder Singh & Ors. …. Respondent(s)
With
CIVIL APPEAL NO.8118/2009
CIVIL APPEAL NO.6933/2009
J U D G M E N T
A.S. Bopanna,J.
The appellants in all the above three appeals are
1.
assailing the order dated 13.08.2009 passed by the National
Consumer Disputes Redressal Commission, New Delhi
(“NCDRC” for short) in Original Petition No.289/1997.
Through the said order, the NCDRC has held the appellants
Signature Not Verified
Digitally signed by
Vishal Anand
Date: 2021.09.07
16:41:03 IST
Reason:
herein guilty of medical negligence and has directed payment
Page 1 of 27
of Rs.17,00,000/ (Rupees Seventeen Lakhs only) with
interest at the rate of 9 % per annum from the date of filing
the complaint till the date of payment. The appellant in Civil
Appeal No.7380/2009 is the doctor who administered
anaesthesia to the patient. The appellant in C.A.
No.6933/2009 is the hospital wherein the operation was
performed. The appeal bearing C.A. No.8118/2009 is filed by
the New India Assurance Company Limited from whom the
anaesthetist and the hospital had taken separate policy to the
extent limited under the policy.
The brief factual matrix leading to the above case is as
2.
here below. The patient Smt. Jasbeer Kaur, wife of the first
claimant and mother of claimants 2 and 3 before the NCDRC
visited the appellant hospital on 08.10.1996 and was
diagnosed with kidney stone in her right kidney. She was
advised to undergo surgery by the treating surgeon Dr. R.K.
Majumdar. The patient who was examined as an outpatient
had come back to the hospital only on 03.12.1996. On being
examined again at that point, it was noticed that the right
kidney had been severely damaged and the left kidney was
also diagnosed with a stone. In medical terms, the diagnosis
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was referred as Hydronephrosis, Grade IV with renal stone in
the right kidney and Hydronephrosis of Grade II in the left
kidney. As advised earlier, the patient was again advised
surgery.
Accordingly, the patient admitted herself on
3.
06.12.1996 and she was declared fit for surgery. On
07.12.1996, Dr. H.K. Khurana informed the patient as also
her husband that both the kidneys could not be operated at
the same time due to the severe damage. They were advised
that as per the medical practice, the less affected kidney that
is the left kidney would be operated in the beginning since
complete removal of the right kidney cannot be ruled out. In
such eventuality, the left kidney if rectified would be able to
function. The appellants contend that on 09.12.1996 an
informed consent of highrisk surgery was obtained from the
patient as well as her husband. The respondent No.1 and Dr.
R.K. Majumdar were involved in performing the surgery of the
left kidney, which was a successful operation. As per the say
on behalf of the hospital and the doctors, the condition of the
patient improved by 12.12.1996 due to which the possibility
of the second surgery to the right kidney was considered. The
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necessary tests conducted by the anaesthetist, the physician
and the surgeon resulted in clearing the patient for the
second surgery.
The second surgery was prepared to be conducted on
4.
16.12.1996 and the patient was taken to the operation
theatre around 9:45 a.m. The appellant in C.A.
No.7380/2009, namely Dr. H.K. Khurana administered the
injections of Pentothal Sodium and Scolin as per the medical
practice. Subsequent thereto, an endotracheal tube of 7.5
mm diameter was inserted in the trachea to give nitrous oxide
and oxygen. The appellants contend that the said standard
procedure was also followed during the first surgery but on
the present occasion the condition of the patient deteriorated,
the blood pressure fell and pulse became feeble. The cardiac
respiratory arrest was noticed. The efforts said to have been
made by the doctors including the physician did not yield
result, though the patient had been put on Boyle’s machine
and necessary oxygen was supplied using the same. In the
evening, the patient is stated to have been put on an
automatic ventilator and was shifted to critical care unit.
Despite the best efforts, the patient expired on 23.12.1996.
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The appellants contend that an issue arose with regard
5.
to the payment of the balance medical bills. When the same
was demanded, since the respondent No.1 i.e the husband of
the deceased was a union leader at Whirlpool India, a
demonstration was held by the workers at the hospital on
06.02.1997 which resulted in the criminal charges in a
criminal complaint being filed against the appellant hospital
and also a magisterial enquiry was conducted. The appellant
hospital is stated to have filed a suit for recovery of the
balance of the medical bills due in C.S. No.332/1997 on
13.08.1997 which according to them had triggered the
criminal complaint and claim for compensation was made as
a counter blast. The criminal complaint is said to have been
filed in FIR No.128 on 27.09.1997. The complaint before the
NCDRC was filed thereafter alleging medical negligence and
claiming compensation which is dated 06.12.1997. The
NCDRC having entertained the same has passed the order
impugned herein.
6. The allegation against the appellant doctor and the
hospital is that they did not exercise the care which was
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required in treating the patient. Though, the operation on the
left kidney conducted on 09.12.1996 was successful, it is
contended that the surgeon who had conducted the operation
namely, Dr. Majumdar had recorded in the case sheet that
the patient has poor tolerance to anaesthesia. It was the
further grievance of the claimants before the NCDRC that the
second operation within the short duration was forced upon
the patient which led to the consequences. Despite the
observation of the surgeon relating to the poor tolerance to
anaesthesia, appropriate care was not taken and the required
medical equipments more particularly the ventilator was not
kept available. Further, the consent of the patient had not
been obtained for the second operation. It was contended that
even after the patient suffered a cardiac arrest proper care
was not taken in having the presence of the cardiologist or a
neurologist. The physician who attended the patient had also
taken some time to change and attend to the patient. It was
therefore contended that the said negligence on the part of
the doctors as well as the hospital had resulted in the death
of the patient.
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The appellants herein, who were the respondents
7.
before NCDRC filed their version denying the case put forth
on behalf of the claimants. It was contended that the high
risk involved in the second operation was made known to the
patient and the cardiac arrest which occurred in the present
case is likely to occur in certain cases for which appropriate
care had been taken by the doctors. The observation relating
to poor tolerance to anaesthesia was explained as not being a
major issue inasmuch as the earlier operation was successful
and was not eventful though anaesthesia had been
administered in the same manner for the first surgery.
8. The claimants as well as the respondents before the
NCDRC had filed their respective affidavits and had also
exchanged interrogatories. No medical evidence was tendered
on behalf of claimants. Based on the same, the NCDRC
arrived at its conclusion.
9. The learned counsel for the appellants in
C.A.No.7380/2009 and C.A. No.6933/2009 made detailed
reference to the history of the patient and the patient’s sheet
maintained by the hospital. In that regard it is pointed out
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that on 13.12.1996 the doctor had recorded that the surgical
recovery which related to the first operation conducted on
09.12.1996, to be excellent. On 14.12.1996, the observation
recorded also indicated that the patient is insisting for
surgery of the other side. In that light, also keeping in view
the requirement of the surgery to the right kidney which was
damaged, a decision was to be taken in that regard. The
informed consent was obtained from the husband of the
patient where the risk factor had also been recorded. It is
contended that every untoward incident cannot be considered
as medical negligence. The learned counsel for the hospital
also has referred to the documents and the facilities available
in the hospital and the care taken by the doctors.
10. The learned counsel for the respondent No.1 would
however dispute the position and contend that the entire
aspect has been taken note by the NCDRC. It is contended
that the observation on 14.12.1996 that the patient is
insisting for surgery of the other side is an insertion. The
learned counsel refers to the circumstances and the sequence
of events that unfolded on 16.12.1996 to contend that
immediately on the anaesthesia being administered, the
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patient had suffered cardiac arrest and the hospital which did
not possess a ventilator was negligent. The Boyle’s apparatus
was not sufficient and the anaesthetist claiming to have
manually operated the same for such long time cannot be
accepted as a correct statement. It is further contended that
the hospital did not possess public address system or paging
service which resulted in the delay in securing the physician
to attend and revive the patient.
11. In the background of the rival contentions, the fact
that a second operation was performed on 16.12.1996 and
the patient had suffered a cardiac arrest after she was
administered anaesthesia appears to be the undisputed
position from the medical records as well as the statement of
the parties. Every death of a patient cannot on the face of it
be considered as death due to medical negligence unless
there is material on record to suggest to that effect. It is
necessary that the hospital and the doctors are required to
exercise sufficient care in treating the patient in all
circumstance. However, in unfortunate cases though death
may occur and if it is alleged to be due to medical negligence
and a claim in that regard is made, it is necessary that
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sufficient material or medical evidence should be available
before the adjudicating authority to arrive at a conclusion.
Insofar as the enunciation of the legal position on this aspect,
the learned counsel for the appellant had relied on the
decision of the Hon’ble Supreme Court in
Jacob Mathew vs.
State of Punjab and Anr. (2005) 6 SCC 1 wherein it has
been held that the true test for establishing negligence in
diagnosis or treatment on the part of a doctor is whether he
has been proved to be guilty of such failure as no doctor of
ordinary skill would be guilty of, if acting with ordinary care.
The accident during the course of medical or surgical
treatment has a wider meaning. Ordinarily an accident
means an unintended and unforeseen injurious occurrence,
something that does not occur in the usual course of events
or that could not be reasonably anticipated. The learned
counsel has also referred to the decision in Martin
(2009) 3 SCC 1 wherein it is
F.D’Souza vs. Mohd. Ishfaq
stated that simply because the patient has not favourably
responded to a treatment given by doctor or a surgery has
failed, the doctor cannot be held straight away liable for
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medical negligence by applying the doctrine of Res Ipsa
Loquitor. It is further observed therein that sometimes despite
best efforts the treatment of a doctor fails and the same does
not mean that the doctor or the surgeon must be held guilty
of medical negligence unless there is some strong evidence to
suggest that the doctor is negligent.
12. The learned counsel for the respondents, on the other
hand, referred to the decision in
V. Kishan Rao vs. Nikhil
Super Speciality Hospital and Another (2010) 5 SCC 513
to contend that the decision in the case of
Martin F.D’Souza
(supra) wherein general directions is given to secure medical
report at preliminary stage is held to be not treated as a
binding precedent and those directions must be confined to
the particular facts of that case. It is held that in a case
where negligence is evident, the principles of
res ipsa loquitur
operates and the complainant does not have to prove
anything and in the said case it is held that in such event it
is for the respondent to prove that he has taken care and
done his duties, to repel the charge of negligence. Though
such conclusion has been reached on the general direction,
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we take note that in V. Kishan Rao (supra) the fact situation
indicated that RW1 had admitted in his evidence that the
patient was not treated for malaria. In that background, it
was taken into consideration that the patient had been
treated for typhoid though the test in that regard was found
negative and the test for malaria was positive. The said fact
situation therefore indicated that the principle of res ipsa
loquitur would apply. It would be apposite to note that in the
very decision this Court has expressed the view that before
forming an opinion that expert evidence is necessary, the
Fora under the Act must come to a conclusion that a case is
complicated enough to require the opinion of an expert or the
facts of the case are such that it cannot be resolved by
members of the Fora without the assistance of the expert
opinion. It is held that no mechanical approach can be
followed and each case has to be judged on its own facts.
In
13. S.K. Jhunjhunwala vs. Dhanwanti Kaur and
Another (2019) 2 SCC 282 referred by the learned counsel for
the respondent, the negligence alleged was of suffering
ailment as a result of improper performance of surgery. It was
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held that there has to be direct nexus with these two factors
to sue a doctor for negligence. In, Nizam’s Institute of
Medical Sciences vs. Prasanth S. Dhananka and Others
(2009) 6 SCC 1 relied upon by the learned counsel for the
respondent, broad principles under which the medical
negligence as a tort have to be evaluated is taken note, as has
been laid down in the case of (supra). The
Jacob Mathew
ultimate conclusion reached in the case of Nizam’s Institute
(supra) relating to the lack of care and caution and the
negligence on the part of the attending doctors was with
reference to the medical report which was available on record
which indicated the existence of tumour located at left upper
chest and in that circumstance the presence of neuro
surgeon was essential and the said procedure not being
adopted, a case of negligence or indifference on the part of the
attending doctors had been proved.
Having noted the decisions relied upon by the learned
14.
counsel for the parties, it is clear that in every case where the
treatment is not successful or the patient dies during
surgery, it cannot be automatically assumed that the medical
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professional was negligent. To indicate negligence there
should be material available on record or else appropriate
medical evidence should be tendered. The negligence alleged
should be so glaring, in which event the principle of
res ipsa
loquitur could be made applicable and not based on
perception. In the instant case, apart from the allegations
made by the claimants before the NCDRC both in the
complaint and in the affidavit filed in the proceedings, there
is no other medical evidence tendered by the complainant to
indicate negligence on the part of the doctors who, on their
own behalf had explained their position relating to the
medical process in their affidavit to explain there was no
negligence. The reference made is to the answers given by Dr.
Khurana to the interrogatories raised by the complainant. In
respect of the first operation, it was clarified that the patient
did not have any side effects/complications during the first
operation which was described as uneventful. On leaving the
operation theatre, the patient was in the custody of surgeon.
After the operation he had not been called for any
complication related to anaesthesia. Since he had written the
anaesthesia notes in the register during the first operation,
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he did not see reason to see the hospital record after the first
operation. With regard to the comment of the surgeon after
the first operation in the treatment sheet regarding the
patient being ‘poorly tolerant to anaesthesia’, he has replied
that the said observation had no meaning since the first
operation was uneventful and was successful. There was no
anaesthesia related complication of any kind. With regard to
the emergency which occurred during the second operation
and the manner in which he had alerted the hospital and
requisitioned the help of cardiologist, he has answered that
the full operation theatre team was already there and the
cardiologist was summoned by one of the members of the
team and the specific details could not be answered by him
since the entire team was busy in attempting to save the
patient.
15. The NCDRC having noted the reply has arrived at the
conclusion that since there was a note that the patient had
poor tolerance to anaesthesia, he had disregarded the
observation without holding any discussion with any other
anaesthesiologist and other specialist. Insofar as the facility
of the paging system the NCDRC had taken note that the
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magisterial enquiry has come to a conclusion that there is no
paging system. The conclusion reached by the NCDRC on
first aspect appears to be an assumption without the backing
of medical evidence. The anaesthetist Dr. Khurana has
claimed to be experienced in the field and in the contention
put forth before the NCDRC has claimed to have successfully
administered anaesthesia to more than 25,000 patients in
elective as well as emergency surgical procedures. Even if the
same is accepted to be a tall claim, the fact remains that he
had sufficient experience of administering anaesthesia.
However, the question was as to whether he was negligent.
That aspect of the matter as to whether in the background of
the medical records, the manner in which he had proceeded
to administer the anaesthesia amounted to negligence could
have been determined only if there was medical evidence on
record. In the instant case it is not a situation that the
diagnosis was wrong. The fact of both the kidneys requiring
to be operated is the admitted position. The two aspects
which are the foundation for allegation of negligence is that
no care was taken despite the observation of the surgeon
after the first surgery that the patient is poorly tolerant to
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anaesthesia. The second aspect is as to whether the patient’s
life was exposed to risk by advising and preparing for the
second operation without sufficient gap after the first
operation. Any of the shortcoming relating to infrastructure
as mentioned in the report of the magisterial enquiry will
become material only if the medical evidence is to the effect
that the said two aspects were not the normal situation and
that undertaking operation in such situation with reference
to the medical condition of the patient was a highrisk
procedure, the backup that ought to have been ensured and
whether the medical equipments that were available at that
point in time were sufficient. Without reference to the
evidence, mere assumption would not be sufficient is the
legal position laid down in the decisions referred above.
Principle of res ipsa loquitur is invoked only in cases the
negligence is so obvious.
The next aspect on which the NCDRC has found fault
16.
with the appellants is regarding the consent being taken only
of her husband for the second surgery. Though the NCDRC
has referred to an earlier decision rendered by the
Commission on this aspect, what is necessary to be taken
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note is that in the instant facts the first operation had been
performed on 09.12.1996 during which time an informed
consent was taken from the patient as also from her
husband. During the second operation the patient was in the
process of recovery from the first operation and the
requirement of second surgery was informed to her. In that
circumstance the informed consent was obtained from the
husband. The noting in the document at Annexure RA3 also
indicates that he has noted that he has been informed about
the high risk of his patient in detail and his consent is given.
Though it was contended before the NCDRC that there was
an interpolation in the patient’s sheet on 14.12.2016, the
informed consent form indicates that it has been written in
hand and signed by the patients’ husband i.e., the first
complainant before NCDRC and consent was given and the
patient was also kept in the loop. The complainant who was
throughout with the patient and who had given his consent
did not make any other contrary noting therein so as to hold
the nontaking of the consent from the patient against the
appellants herein.
Page 18 of 27
17. On the aspect relating to the noting regarding poor
tolerance to anaesthesia though the NCDRC has reached the
conclusion that he had not taken care of such observation,
the very fact that the NCDRC had noted that Dr. Khurana
was the anaesthetist during the first surgery could not have
been held against him since in the said circumstance he was
aware about the details of the patient to whom he had
administered anaesthesia for the first surgery. When it is
shown that the earlier operation was uneventful, in the
absence of any medical evidence brought on record to the
contrary regarding the failure on the part of Dr. Khurana in
taking any steps while administering anaesthesia for the
second operation, the observation of poor tolerance in the
case sheet by itself cannot be assumed as negligence. It is no
doubt unfortunate that the patient had suffered cardiac
arrest. The procedure which was required to be followed
thereafter has been followed as per the evidence put forth by
the appellant and the consequences has been explained by
them. To arrive at the conclusion that there was negligence,
the medical evidence to point out negligence in administering
anaesthesia even in that situation was required to be
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tendered since the adjudicating authority is not an expert in
the field of medicine to record an independent opinion.
18. The NCDRC has placed much reliance on the enquiry
report which cannot be treated as contra medical evidence as
compared to the evidence tendered by the appellants. The
observation contained in the judgment of the criminal case
decided on 27.11.2006, which has been referred to by the
NCDRC to form its opinion that the said observation amounts
to a situation that there was some serious medical negligence
is not the correct position. The conclusion is not that there
was negligence but keeping in view the standard of proof that
is required in a criminal trial to establish gross negligence, an
alternate statement was made by the Court stating that even
if there is some negligence the same cannot be considered as
gross negligence. Such observation was not a finding
recorded that there was negligence. So far as the reliance
placed on an enquiry that was conducted by the District
Magistrate, the same cannot be considered as medical
evidence to hold negligence on the part of the doctors or the
hospital in the matter of conducting the second surgery and
the condition of the patient in the particular facts of this
Page 20 of 27
case. Though, the civil surgeon was a member of the two
member committee which conducted the enquiry and certain
adverse observations were made therein, the conclusion
therein is not after assessing evidence and providing
opportunity to controvert the same. Based on the statements
that have been recorded and the material perused, an opinion
has been expressed which cannot be the basis to arrive at a
conclusion in an independent judicial proceeding where the
parties had the opportunity of tendering evidence. In such
proceeding before the NCDRC the appellants have tendered
their evidence in the nature of affidavit and if the same is
insufficient the cause would fail. The observations contained
in the order of NCDRC is in the nature of accepting every
allegation made by the claimant regarding the sequence and
delay in the doctors attending to rectify the situation as the
only version and has not been weighed with the version put
forth by the doctors.
On the principle of res ipsa loquitur, the NCDRC has
19.
taken note of an earlier case wherein the conclusion reached
was taken note in a circumstance where the anaesthesia had
killed the patient on the operating table. In the instant facts,
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the patient had undergone the same process of being
administered anaesthesia for the first operation and the
operation had been performed successfully and the entire
process was said to be uneventful. Though in the second
operation, the patient had suffered a cardiac arrest, the
subsequent processes with the help of the Boyle’s apparatus
had been conducted and the patient had also been moved to
the CCU whereafter the subsequent efforts had failed. The
patient had breathed her last after few days. As already
noted, there was no contrary medical evidence placed on
record to establish that the situation had arisen due to the
medical negligence on the part of the doctors.
20. The very questions raised by the NCDRC at issue Nos.2
to 7 would indicate that in the present fact situation the first
operation performed by the same team of doctors in the same
hospital was successful and the unfortunate incident
occurred when the second operation was scheduled. Hence
what was required to be determined was whether medically,
the second operation could have been conducted or not in
that situation and whether the medical condition of the
patient in the present case permitted the same. The issues
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raised by framing the other questions would have arisen
depending only on the analysis of the medical evidence on
those issues at 2 to 7 more particularly issues 2 and 3.
In addition to what has been noted above, in the
21.
context of the issues which had been raised for consideration,
the verbatim conclusion reached by the NCDRC would be
relevant to be noted. The issues No. 2 and 3 which were
raised for consideration are the crucial issues which entirely
was on the medical parlance of the case. The said issues
were to the effect as to whether the second surgery should
have been undertaken since it was recorded that the patient
has poor tolerance to anaesthesia and whether the surgery of
the second kidney should have been taken within eight days
from the first surgery though it was not an emergency. As
noted, the appellants being doctors had tendered their
affidavits indicating that as per the medical practice the same
was permissible. On behalf of the claimants no medical
evidence was tendered. Though from the available records
the NCDRC could have formed its opinion with reference to
medical evidence if any, the nature of the conclusion recorded
is necessary to be noted.
Page 23 of 27
“We are surprised to note that the treating doctor after
recording that the patient had poor tolerance to
anaesthesia has tried to defend his action by stating
that poor tolerance to anaesthesia means nothing.”
“However, we cannot be oblivious of the fact that Dr.
Khurana was the Anaesthesiologist during the first
surgery also and he was fully aware of the conditions of
the patient. In reply to the interrogatories, he has clearly
admitted that he has gone through the notings of Dr.
Mazumdar wherein he has said the patient has poor
tolerance to anaesthesia. We are stunned to note that he
has stated in the reply to interrogatories that in medical
parlance poor tolerance to anaesthesia means nothing'.”
“It is common knowledge that a person can survive with
one kidney, just as a person can survive with one lung.
There are cases where a patient suffers from failure of
both the kidneys and nephrectomy is performed to
replace one of the damaged kidneys by a kidney of a
donor after proper test and verification. Therefore, there
was no hurry to perform the second surgery.”
The extracted portion would indicate that the opinion as
expressed by the NCDRC is not on analysis or based on
medical opinion but their perception of the situation to
arrive at a conclusion. Having expressed their personal
opinion, they have in that context referred to the principles
declared regarding Bolam test and have arrived at the
conclusion that the second surgery should not have been
taken up in such a hurry and in that context that the
appellants have failed to clear the Bolam test and therefore
Page 24 of 27
they are negligent in performing of their duties. The
conclusion reached to that effect is purely on applying the
legal principles, without having any contra medical evidence
on record despite the NCDRC itself observing that the
surgeon was a qualified and experienced doctor and also
that the anaesthetist had administered anaesthesia to
25,000 patients and are not ordinary but experienced
doctors.
22. On the aspect relating to the observation of poor
tolerance to anaesthesia and the period of performing the
second operation from the time of first operation was
conducted it was a highly technical medical issue which was
also dependant on the condition of the patient in a
particular case which required opinion of an expert in the
field. There was no medical evidence based on which
conclusion was reached with regard to the medical
negligence. The consequential issues with regard to the
preparation that was required and the same not being in
place including of having a cardiologist in attendance are all
issues which was dependant on the aspect noted above on
issues No.2 and 3. The observations of the NCDRC in their
Page 25 of 27
opinion appears to be that the second operation ought not to
have been conducted and such conclusion in fact had led to
the other issues also being answered against the appellants
which is not backed by expert opinion.
In the above circumstance when there was no medical
23.
evidence available before the NCDRC on the crucial medical
aspect which required such opinion, the mere reliance
placed on the magisterial enquiry would not be sufficient.
Though the opinion of the civil surgeon who was a member
of the committee is contained in the report, the same cannot
be taken as conclusive since such report does not have the
statutory flavour nor was the civil surgeon who had
tendered his opinion available for crossexamination or
seeking answers by way of interrogatories on the medical
aspects. Therefore, if all these aspects are kept in view, the
correctness or otherwise of the line of treatment and the
decision to conduct the operation and the method followed
were all required to be considered in the background of the
medical evidence in the particular facts of this case. As
indicated, the mere legal principles and the general standard
of assessment was not sufficient in a matter of the present
Page 26 of 27
nature when the very same patient in the same set up had
undergone a successful operation conducted by the same
team of doctors. Hence, the conclusion as reached by the
NCDRC is not sustainable.
For the aforesaid reasons, the order dated 13.08.2009
24.
passed in O.P. No.289 of 1997 is set aside. The appeals are
accordingly allowed. There shall be no order as to costs.
25. Pending application, if any, shall stand disposed of.
.………………….…J.
(HEMANT GUPTA)
……………………J.
(A.S. BOPANNA)
New Delhi,
September 07, 2021
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