Full Judgment Text
Reportable
2025 INSC 1094
IN THE SUPREME COURT OF INDIA
CIVIL APPELLATE JURISDICTION
CIVIL APPEAL NO. 1662 OF 2016
Deep Nursing Home and another … Appellants
Versus
Manmeet Singh Mattewal and others … Respondents
J U D G M E N T
SANJAY KUMAR, J
Manmeet Singh Mattewal, respondent No. 1, lost his wife,
Charanpreet Kaur, and his newborn son within the span of a few hours.
Shiraz Mattewal, respondent No.2, is his older son. Our sympathies
aside, we are called upon to examine the validity of the finding that
Dr. (Mrs.) Kanwarjit Kochhar, appellant No.2, the Obstetrician/
Gynaecologist who conducted the delivery is guilty of medical
negligence and deficiency in service. By judgment dated 31.01.2007 in
Complaint Case No. 56 of 2006, the State Consumer Disputes
Signature Not Verified
Digitally signed by
babita pandey
Date: 2025.09.09
18:03:47 IST
Reason:
1
Redressal Commission, Union Territory, Chandigarh , had found her and
1
for short, ‘the SCDRC’
1
Deep Nursing Home, Chandigarh, appellant No.1, medically negligent on
the ground that they did not exercise due care and caution in treating
Charanpreet Kaur but held that there was no fault on their part insofar as
the death of the newborn child was concerned. The SCDRC directed
them to pay 20,26,000/- to the complainants, Manmeet Singh Mattewal
₹
and Shiraz Mattewal. However, as they were covered by the insurance
policy issued by New India Assurance Company Limited, respondent No.
3 herein, the company was directed to pay 20,00,000/- and the balance ₹
was directed to be paid by them. Interest @ 9 % was awarded if the
amount was not paid in one month. Costs of 10,000/- ₹ were also
awarded.
2. Deep Nursing Home, Chandigarh, and Dr. Kanwarjit Kochhar filed
First Appeal No. 158 of 2007 before the National Consumer Disputes
2
Redressal Commission, New Delhi , assailing the SCDRC’s judgment.
First Appeal No. 193 of 2007 was filed separately by New India
Assurance Company Limited. However, by order dated 09.05.2012, the
NCDRC dismissed both appeals. Therein, the NCDRC came to the
conclusion that no liability would attach to Deep Nursing Home,
Chandigarh, and pinned the entire responsibility of paying 20,26,000/- ₹
upon Dr. Kanwarjit Kochhar. As 6,00,000/- had already been deposited ₹
pursuant to its order dated 12.04.2007 and was withdrawn by Manmeet
2
for short, ‘the NCDRC’
2
Singh Mattewal, the NCDRC directed her to pay the balance sum of
₹ 14,26,000/- in 6 weeks along with costs of 14,000/-. In the passing, ₹
we may note that the NCDRC reserved judgment in the appeals on
27.07.2010 but the order was pronounced by it nearly two years later, on
09.05.2012!
3. Despite the clean chit given to it by the NCDRC, Deep Nursing
Home, Chandigarh, joined Dr. Kanwarjit Kochhar in filing the special
leave petition from which the present appeal arises. By order dated
10.02.2014, this Court directed a further sum of 4,00,000/- to be paid to ₹
Manmeet Singh Mattewal and Shiraz Mattewal, respondent Nos. 1 and 2
herein. Leave was granted by this Court on 15.02.2016.
4. At the outset we may note that, in Universal Sompo General
3
Insurance Co. Ltd. vs. Suresh Chand Jain and another , this Court
affirmed that a special leave petition under Article 136 of the Constitution
is not the proper remedy against an appellate order passed by the
NCDRC. However, as this matter was entertained and has been pending
on the file of this Court for over twelve years, we do not think it proper to
relegate the appellants at this late stage to the alternative remedy under
Article 226 of the Constitution before the jurisdictional High Court.
5. We may now note the contents of Complaint Case No. 56 of 2006
filed before the SCDRC: Charanpreet Kaur, a co-operative bank
3
(2024) 9 SCC 148
3
manager on deputation as a lecturer in the Punjab Institute of
Cooperative Training, was aged about 32 years and was earning a
th
monthly salary of 25,682/-. She was in the 8 ₹ month of her pregnancy
when she started consulting Dr. Kanwarjit Kochhar of Deep Nursing
Home, Chandigarh. According to the complaint case, she visited the
nursing home several times and also underwent the tests prescribed
from time to time. Photocopies of the ultrasound tests done on
08.08.2005, 11.11.2005 and 16.12.2005 were filed in this regard. It was
stated that the couple visited the nursing home on 10.11.2005,
29.11.2005 and 09.12.2005 for check-ups and were assured that all was
well and that it would be a normal delivery. A copy of the prescription
dated 10.11.2005, with entries, was also filed. Charanpreet Kaur was
admitted on 21.12.2005 at about 11.00 AM for delivery. However, the
newborn child died instantly after birth, which took place at 02.00 AM on
the next day. It was alleged that the nursing home was ‘inadequately and
ill equipped’ to handle emergencies during deliveries and there were no
facilities available in that regard.
6. According to the averments made, the mother was informed about
the death of the newborn child which resulted in her going into shock
and caused profuse bleeding. It was alleged that no blood was readily
available in the nursing home for transfusion and the delay in shifting her
to the Post Graduate Institute of Medical Education and Research,
4
4
Chandigarh , at 05.30 AM resulted in her being declared ‘brought dead’
on arrival. It was further alleged that the staff of Deep Nursing Home did
not bring any reference papers or history sheet to facilitate her treatment
at the PGI. The van in which she was taken was also ill-equipped and it
was claimed that no doctor accompanied her in the said van. It was
alleged that Dr. GS Kochhar, the husband of Dr. Kanwarjit Kochhar, who
represented Deep Nursing Home, Chandigarh, chose to follow the van in
his car separately and, therefore, there was no qualified doctor in the
van.
7. Thus, the specific allegations levelled against the nursing home
and the doctor were that the nursing home was not equipped to handle
emergencies and complications during deliveries; the record of the
treatment was fabricated later to escape prosecution; the blood group of
Charanpreet Kaur was not checked and this led to delay in blood
transfusions; the death of the newborn child was also due to negligence;
there was negligence in causing trauma to Charanpreet Kaur by
informing her of the death of the newborn which resulted in shock and
bleeding; and the nursing home had no stock of blood readily available
for transfusion. The complainants sought compensation of 95,21,000/- ₹
along with interest @ 18% per annum, medical expenses of 10,000/- ₹
4
for short, ‘the PGI’
5
and litigation expenses of 11,000/-. This complaint case was filed on ₹
11.05.2006.
8. A lengthy written statement was filed by the opposite parties, viz .,
Deep Nursing Home and Dr. Kanwarjit Kochhar. Therein, they pointed
out that Manmeet Singh Mattewal had earlier reported the matter to the
Senior Superintendent of Police, Chandigarh, and an enquiry was
conducted by a Medical Board, consisting of experts, to ascertain
whether there was any medical negligence and the Board had negated
the same. It was stated that Charanpreet Kaur had suffered atonic Post
5
Partum Haemorrhage which proved to be catastrophic as she did not
respond to the treatment administered in the nursing home. It was stated
that PPH is a failure of the uterus to properly contract after the child is
born resulting in bleeding within the uterus, which cannot be controlled. It
was asserted that proper treatment was given as per protocol but
despite the same, she did not respond and ultimately died. Details were
given of the experience and expertise of Dr. Kanwarjit Kochhar and the
well-equipped status of the nursing home. It was stated that Dr. GS
Kochhar, who ran the nursing home, was a renowned anaesthetist.
Charanpreet Kaur was stated to have come to the nursing home on
10.11.2005 along with her mother and another person. Her date of
delivery was approximated to be around 02.01.2006. As she wanted to
5
for short, ‘PPH’
6
have her delivery at the nursing home with Dr. Kanwarjit Kochhar, she
was advised to continue with the intake of Iron and Calcium. It was
stated that Charanpreet Kaur did not show the reports of her earlier
check-ups, despite being asked by Dr. Kanwarjit Kochhar, and neither
did she show records of her previous delivery. It was further stated that
Dr. Kanwarjit Kochhar came to know from the hushed tones of
Charanpreet Kaur that there was some problem in the delivery of the first
child, but this was not divulged to her. She claimed that she later came
to know that the first child was autistic, but this was also not disclosed to
her. She asserted that, had this fact come to her knowledge earlier, she
might have refused to undertake the delivery, as there were more
chances of the second child having congenital abnormalities if the first
child had them.
9. The written statement then went on to state as follows:
Charanpreet Kaur’s check-ups were on 29.11.2005 and 09.12.2005. As
per their advice, Charanpreet Kaur had informed them that she had
consulted a cardiologist but she did not show any report thereof. Again,
on 16.12.2005, Charanpreet Kaur came for a routine check-up and was
advised to continue with her earlier medication. On 21.12.2005, at about
11.00 AM, Charanpreet Kaur was admitted in the nursing home as she
was suffering from back pain, but she was not in labour. Labour was
induced and she was making good progress. At about 01.00 AM on
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22.12.2005, she was having strong contractions. Dr. RP Bansal, a
qualified paediatrician, was present with the patient from 02.15 AM
onwards. The delivery took place at 02.40 AM, but the newborn child did
not cry. The baby was handed over to the paediatrician for resuscitation
and oxygen was administered through a nasal tube. However, all efforts
to save the baby failed and he was declared dead at 03.10 AM. The
mother was not informed about the death of the baby. The near relations
were informed about it and were advised to get an autopsy done to
ascertain the exact cause of death of the child. However, they refused to
do so.
10. Details were furnished of the treatment given to Charanpreet Kaur
post-delivery and it was stated that there were no placental tissue or
membranes in her uterus. The cervix was also examined and no tear
was found. However, as there was still bleeding, her relations were
asked to secure two units of blood from the blood bank in Sector 37,
Chandigarh. Dr. GS Kochhar telephonically informed the blood bank to
keep the same ready without delay. Transfusion was commenced at
about 04.15 AM. Owing to the complications which had arisen, two more
doctors, viz ., a senior Gynaecologist and a General Surgeon were
contacted, and they reached the nursing home at 04.00 AM. All the
doctors present conducted a thorough examination and opined that the
patient was suffering from uterine inertia PPH and it was decided that
8
she should be sent to the PGI. The staff of the septic labour room at the
PGI were informed in advance to be ready to receive and treat her. She
was shifted in an ambulance with running blood transfusion and an
Ambu bag (oxygen). Two staff nurses from the nursing home
accompanied her while Dr. GS Kochhar went there in his own car. He
personally took the patient on a stretcher to the septic labour room. On
his request, completion of the other formalities prior to admission were
kept on hold. During the journey, the patient suffered a bout of bleeding
and was in deep shock. After reaching the PGI, she was examined but
no pulse and heart beat were palpable. Despite resuscitative measures,
she did not survive. The patient developed uterine inertia PPH which is a
disorder with poor prognosis and high mortality. Uterine Artery
Embolization facility was available only in the PGI in the whole of North
India. The blood group of Charanpreet Kaur was checked and the same
was written on the prescription dated 10.11.2005 itself, which had been
filed with the complaint. It was denied that the nursing home was ill-
equipped to handle emergencies during deliveries. It was asserted that
there was no delay in shifting the patient to the PGI.
11. No rejoinder was filed by the complainants to the above written
statement.
12. The SCDRC, vide its judgment dated 31.01.2007, found fault with
Dr. Kanwarjit Kochhar for not getting Charanpreet Kaur’s blood group
9
identified at the time of delivery and in arranging for transfusion by
keeping blood supply ready. Reference was made to a textbook on
Obstetrics and Gynaecology by the SCDRC and it was opined that, in a
case of PPH, excessive bleeding after child birth is the single largest
cause of maternal deaths worldwide. The SCDRC came to the
conclusion that the nursing home and Dr. Kanwarjit Kochhar wasted
almost two hours in getting blood and cross-matching it and this led to
deterioration of the patient’s condition. Examining the averments in the
written statement, the SCDRC found fault with Dr. GS Kochhar for not
accompanying the patient in the ambulance to the PGI. The SCDRC
went to the extent of doubting his very presence there. The conclusion
drawn by the SCDRC was that Charanpreet Kaur was already dead
when she was taken to the PGI and this was done only to dump her
dead body there. The affidavit filed by Dr. GS Kochhar was held to be
a false and fabricated document and the SCDRC categorically recorded
a finding that he did not go to the PGI. Reference was made to the
Report dated 18.08.2006 of the Medical Board at Government Medical
College and Hospital, Sector 32, Chandigarh, which opined that ‘there
did not appear any gross medical negligence in the management of the
patient by the treating doctors’ but the same was discarded on the
ground that it was a short report without reasons for recording such a
finding. The SCDRC held that it was certainly a case of negligence on
10
the part of the nursing home and Dr. Kanwarjit Kochhar and they had
failed to exercise due care and caution in treating Charanpreet Kaur,
even if it was presumed that there was no fault on their part insofar as
the death of the child was concerned. The SCDRC, accordingly, directed
payment of compensation as stated hereinabove.
13. In appeal, as demonstrated by the impugned order, the NCDRC
observed that Charanpreet Kaur’s death was investigated quite
thoroughly by successive Medical Boards, appointed specifically for that
purpose on complaints of gross negligence made by Manmeet Singh
Mattewal to various authorities of the State Government. Before the
NCDRC, it was stated on behalf of the appellants that the delivery was
complete only at about 03.00 AM after the patient expelled the placenta.
It was contended that in a normal delivery, as was the case here, the
uterus would gradually contract on its own after the delivery and the
bleeding would stop but, in this case, the uterus did not contract fully and
went into a phase of relaxation after the initial contraction. It was stated
that, the unusual nature of the bleeding could be known only after it was
verified that it was not from any tear in the vagina or the cervix or from
the site of the episiotomy and all this took some time, as detailed in the
medical record. It could be concluded only around 03.15 AM that the
uterus had not contracted. It was pointed out that, in the course of a
normal delivery, units of blood are not kept ready for transfusion and,
11
therefore, the assumption of the SCDRC, that there was delay and that
the time taken to get the blood was two hours, was factually incorrect. It
was asserted that the patient’s medical record showed that the
transfusion was started in less than an hour of the diagnosis of the
possible cause of bleeding, i.e., atonic uterus. It was also pointed out
that the SCDRC’s conclusion that the patient’s blood group was not
recorded was erroneous. The first page of the medical record showed
that the patient’s blood group was noted right at the beginning but before
starting blood transfusion, every unit of blood has to be necessarily
cross-matched with that of the patient, and this was done in the present
case also. It was asserted that there was no delay in shifting the patient
to the PGI and that all possible care was taken during that process. She
was accompanied by two nurses from the nursing home with a unit of
blood being transfused simultaneously on each arm along with oxygen
supply. Dr. GS Kochhar preceded the van in his car to ensure that there
was no delay in taking her to the septic labour room. It was pointed out
that five Medical Boards had examined the case record and concluded
that, neither in dealing with the newborn’s asphyxia nor in treating the
mother for the sudden complication of atonic PPH, Dr. Kanwarjit Kochhar
had committed any act of medical negligence. All the experts who
constituted these Boards found that there was no negligence on her part
or on the part of the nursing home.
12
14. The NCDRC dealt with each of the Medical Board Reports in turn,
viz ., the first Report dated 23.01.2006 by a Board of four doctors from
the Government Hospital, Sector 16, Chandigarh; the second Report
dated 20.03.2006 of a Board of five doctors from the Government
Medical College and Hospital, Sector 32, Chandigarh; the third Report
dated 03.04.2006 of the reconstituted Committee of four doctors from
the Government Medical College and Hospital, Sector 32, Chandigarh;
and the fourth Report dated 18.08.2006 of a Committee of seven doctors
constituted under the Chairmanship of the Director, Health Services,
Union Territory, Chandigarh. The undated fifth and final Report of four
doctors was also from the Government Medical College and Hospital,
Sector 32, Chandigarh, but it was not taken note of by the NCDRC.
15. The NCDRC, thereupon, looked into medical literature and
copiously extracted from such literature in its order. It noted that
Charanpreet Kaur was under the medical care of Dr. Kanwarjit Kochhar
nd
from the 32 week of her pregnancy through childbirth. It was noted that
she had gone to some other Obstetrician during the earlier part of her
second pregnancy. Noting the claim made by Dr. Kanwarjit Kochhar that
she was not told details of the delivery of the first child but her suspicion
that there was some problem therewith, the NCDRC observed that it was
the minimum professional requirement for her to have gathered such
information. The NCDRC also found fault with the medical record
13
maintained by the nursing home after Charanpreet Kaur’s first visit. It
was noted that Dr. Kanwarjit Kochhar had claimed that the prior medical
record was not given to her and the NCDRC opined that she had failed
to ascertain information which had crucial implications, i.e., with regard
to Charanpreet Kaur’s haematological status. We may observe, at this
stage, that the NCDRC seems to have visualized itself in the role of a
medical professional and expressed purported expert opinions on how
Dr. Kanwarjit Kochhar ought to have acted as an Obstetrician when
Charanpreet Kaur came to her initially and as to how she should have
gone about prescribing tests!
16. In effect, the NCDRC opined that, though all the Medical Boards
had opined that there did not appear to be any gross medical negligence
in the management of the patient by the treating doctors after the
delivery, the same did not mean that there was no medical negligence
before the delivery. As per the NCDRC, there were several instances of
departure from standard protocols in the antenatal care of the patient on
the part of Dr. Kanwarjit Kochhar as she failed to insist on the patient
getting standard haematological investigations done. According to the
NCDRC, no case of tortious medical negligence was made out against
Dr. Kanwarjit Kochhar in handling Charanpreet Kaur’s labour, including
the delivery, the management of the baby, the baby’s problem and the
post-delivery management at the nursing home, but there was enough
14
evidence as well as expert opinion to hold that antenatal management of
Charanpreet Kaur by Dr. Kanwarjit Kochhar, particularly, in respect of
necessary haematological and cardiological investigations, was not in
accordance with the standard protocols that an Obstetrician of average
skill would adopt. It further held that no case of medical negligence/
deficiency in service was made out against the nursing home as there
was nothing in the Medical Boards’ Reports on this aspect and the
complainants did not lead any reliable evidence in support of their
allegations in this regard. The NCDRC, therefore, concluded that no
liability could attach to the nursing home. The NCDRC noted that,
pursuant to its direction on 12.04.2007, Manmeet Singh Mattewal had
withdrawn ₹ 6,00,000/- deposited by the nursing home and the insurance
company and directed that the balance amount due be paid by Dr.
Kanwarjit Kochhar.
17. It would be apposite at this stage to note the contents of the
Medical Boards/Committees’ Reports. The first Report dated 23.01.2006
was furnished by the Board of doctors from Government Hospital, Sector
16, Chandigarh. This Board comprised Dr. Rupinder Kaur, Dr. Vidhu
Bhasin and Dr. N.K. Kaushal. After perusing the record, the Board
opined that the patient had died because of severe atonic PPH which did
not respond to the treatment given at the nursing home. It was recorded
that the treatment given was as recommended and that blood is not
15
arranged beforehand for normal deliveries. It was noted that the blood
samples were sent for cross-matching at 03.15 AM; that the patient went
into shock at 03.45 AM, that blood was brought from Rotary and Blood
Bank Society, Sector 37, Chandigarh; that blood transfusion was started
at 04.15 AM on both arms; and she was then referred to the PGI.
18. The second Report dated 20.03.2006 was from a Board of doctors
of Government Medical College and Hospital, Sector 32, Chandigarh.
The doctors in this Board were Professor Veena Parmar, HoD of
Paediatrics; Professor Anju Huria, HoD of Obstetrics & Gynaecology;
Professor K.K. Gombar, HoD of Anaesthesia; Professor A.K. Attri, HoD
of Surgery; and Professor Harsh Mohan, Medical Superintendent and
HoD of Pathology (Chairman). The conclusion of the Board was that the
patient had atonic PPH which was managed conservatively but without
success. It was noted that PPH is a known complication of delivery and
accounted for 8% of maternal mortality in developed countries. The
Board opined that different patients may cope differently with blood loss
in PPH - a healthy woman would be far more tolerant to blood loss of 30-
50% when compared to a woman with either pre-existing anaemia or
underlying cardiac complications or pre-eclampsia. The Board opined
that it could not be said with certainty from the record whether this
patient had anaemia or hypotension and shock before delivery but in the
presence of either or both of these conditions, atonic PPH was more
16
likely to be catastrophic. This final conclusion of the Board did not indict
Dr. Kanwarjit Kochhar but left the question open as it was not clear from
the record whether the patient had any of these conditions before the
delivery.
19. The third Report dated 03.04.2006 was submitted by a Committee
of doctors from the Government Medical College and Hospital, Sector
32, Chandigarh, comprising Professor A.K. Attri, HoD of Surgery
(Chairman); Dr. Satinder Gombar, Professor and HoD of Anaesthesia;
Dr. Anju Huria, HoD of Obstetrics & Gynaecology; and Dr. Suksham
Jain, Assistant Professor of Paediatrics. This Committee, after perusing
the record submitted by the Office of the Director, Health and Welfare,
Chandigarh Administration, discussed the previous reports submitted by
the teams of doctors from the General Hospital, Sector 16, Chandigarh,
and the Government Medial College and Hospital, Sector 32,
Chandigarh, and upon perusal of the medical record and the medical
reports and after thorough deliberations, the Committee opined that
there was no gross medical negligence in the management of the
patient.
20. The fourth Report from the Government Medical College and
Hospital, Sector 32, Chandigarh was dated 18.08.2006. This report was
consequential to the letter dated 15.06.2006 of the Senior
Superintendent of Police, Union Territory, Chandigarh. This Committee
17
consisted of Dr. Manjit Singh Bains, Director, Health Services, General
Hospital, Sector 16, Chandigarh (Chairman); Dr. Usha Bishnoi, Medical
Superintendent, General Hospital, Chandigarh; Professor Harsh Mohan,
Medical Superintendent, Government Medical College and Hospital,
Sector 32, Chandigarh; Professor K.K. Gombar, HoD of Anaesthesia;
Professor Veena Parmar, HoD of Paediatrics; Professor Anju Huria, HoD
of Gynaecology.; and Dr. A.K. Attri, HoD of Surgery. The Committee
deliberated on the issue addressed in the letter and considered the
records of the deceased mother and child provided by the police
department. The Committee also discussed the reports submitted
previously by the teams of doctors from the General Hospital, Sector 16,
Chandigarh, and the Government Medical College and Hospital, Sector
32, Chandigarh. After considering the said records and reports, the
Committee opined that there did not appear to be any gross medical
negligence in the management of the patients by the treating doctors.
21. The fifth and final undated Report was also from the Government
Medical College and Hospital, Sector 32, Chandigarh. This Committee
comprised Professor A.K. Attri, HoD of Surgery (Chairman); Dr. Satinder
Gombar, Professor and HoD of Anaesthesia; Dr. Anju Huria, HoD of
Obstetrics and Gynaecology; and Dr. Suksham Jain, Assistant Professor
of Paediatrics. The Committee perused the whole record submitted by
the Office of the Director, Health and Welfare, Chandigarh
18
Administration, and discussed the previous reports submitted by the
teams of doctors. After thorough deliberations and perusal of the medical
records and the reports, the Committee opined that there was no gross
medical negligence in the management of the patients.
22. Significantly, all the above reports came about upon the instigation
and at the behest of Manmeet Singh Mattewal himself, who seems to
have approached various authorities voicing his grievance against Dr.
Kanwarjit Kochhar and the nursing home in relation to the death of his
wife and child. However, except for one report which, owing to lack of
sufficient data, left one question open, i.e., the possible pre-existing
conditions that may have led to the death of Charanpreet Kaur, none of
the reports held Dr. Kanwarjit Kochhar negligent. Further, given the
settled legal position that every failure in the treatment of a patient does
not automatically lead to an assumption of medical negligence, we find
that the opinions expressed by the doctors and experts, who constituted
these Medical Boards/Committees, clearly tilted the balance in favour of
Dr. Kanwarjit Kochhar, as none of them found any medical negligence
on her part. As already noted hereinbefore, these bodies were
constituted at the behest of Manmeet Singh Mattewal himself and he
cannot, therefore, fight shy of the conclusions and findings rendered by
them.
19
23. As pointed out in Jacob Mathew vs. State of Punjab and
6
another , simply because a patient did not favourably respond to the
treatment given by a physician or if a surgery failed, the doctor cannot be
held liable per se by applying the doctrine of res ipsa loquitur. This edict
7
was reiterated in Martin F. D'Souza vs. Mohd. Ishfaq wherein, it was
pointed out that no sensible professional would intentionally commit an
act or omission which would result in harm or injury to a patient as the
reputation of that professional would be at stake and a single failure may
cost him or her dear in that lapse. It was also pointed out that
sometimes, despite best efforts, the treatment by a doctor may fail but
that does not mean that the doctor or surgeon must be held guilty of
medical negligence, unless there is some strong evidence to suggest
that he or she is. It was also pointed out that Courts and Consumer Fora
are not experts in medical science and must not substitute their own
views over that of specialists. While acknowledging that the medical
profession had been commercialised to some extent and there were
doctors who depart from their Hippocratic Oath for their selfish ends of
making money, this Court held that the entire medical fraternity cannot
be blamed or branded as lacking in integrity or competence just because
of some bad apples.
6
(2005) 6 SCC 1
7
(2009) 3 SCC 1
20
24. On the same lines, in Devarakonda Surya Sesha Mani and
8
others vs. Care Hospital, Institute of Medical Sciences and others ,
it was held that unless a complainant is able to establish a specific
course of conduct, suggesting a lack of due medical attention and care,
it would not be possible for the Court to second-guess the medical
judgment of the doctor on the line of treatment which was administered
and, in the absence of such material disclosing medical negligence, the
Court cannot form a view at variance, as every death in the
institutionalised environment of a hospital does not necessarily amount
to medical negligence on a hypothetical assumption of lack of due
medical care.
25. In any event, the NCDRC’s ultimate conclusion was that there was
negligence on the part of Dr. Kanwarjit Kochhar only in the antenatal
care and management of Charanpreet Kaur. More importantly, the
NCDRC rendered a clear finding that there was no medical negligence in
the handling of Charanpreet Kaur’s labour, including her delivery; the
management of the baby’s problem; and the post-delivery management
at the nursing home. These conclusions, arrived at by the NCDRC, not
only reversed the findings of the SCDRC but also turned the very case
put forth by the complainants on its head. In fact, the NCDRC decided
the matter by building up a new case altogether!
8
2022 SCC OnLine SC 1608
21
26. The specific claim of Manmeet Singh Mattewal in Complaint Case
No. 56 of 2006 was that there was medical negligence on the part of
Dr. Kanwarjit Kochhar and the nursing home in the post-delivery
treatment only, as sufficient facilities were not available in the nursing
home to deal with post-delivery emergencies, and Dr. Kanwarjit Kochhar
failed to take adequate care and caution after the delivery to save the life
of the patient. He categorically asserted that the nursing home was
‘inadequately and ill equipped’ to handle emergencies during deliveries
and there were no facilities available in that regard. His further allegation
was that Charanpreet Kaur was informed about the death of the
newborn child which resulted in her going into shock and caused profuse
bleeding. However, this was not proved and neither the SCDRC nor the
NCDRC recorded a finding on this aspect. His further allegation was that
there was delay in arranging for blood transfusions and there was
negligence during the transfer of Charanpreet Kaur from the nursing
home to the PGI. He made no allegations whatsoever to the effect that
the antenatal care and management of Charanpreet Kaur were deficient
in any manner. On the contrary, he specifically asserted that various
tests were prescribed by Dr. Kanwarjit Kochhar and Charanpreet Kaur
underwent all such tests.
27. The SCDRC had accepted Manmeet Singh Mattewal’s case and
held that negligence was attributable to Dr. Kanwarjit Kochhar and the
22
nursing home in relation to the post-delivery care and treatment of
Charanpreet Kaur. However, this finding was reversed by the NCDRC,
as is evident from the impugned order, wherein the NCDRC held in clear
terms that no liability attached to the nursing home and it was Dr.
Kanwarjit Kochhar who was to be held responsible on the ground of
medical negligence in the antenatal care and management. The specific
finding of the NCDRC was that Dr. Kanwarjit Kochhar had not prescribed
the requisite haematological tests for Charanpreet Kaur.
28. This was never the case of Manmeet Singh Mattewal. The entire
focus of the NCDRC, however, was only upon the antenatal care and
management of the patient and its pinpointed findings were also in
relation to the said period and treatment only. The NCDRC’s observation
that there were several instances of departure from standard protocols in
the antenatal management of the patient, such as, not getting proper
tests done, and its final finding that no case of tortious medical
negligence was made out against Dr. Kanwarjit Kochhar in handling
Charanpreet Kaur’s labour, her delivery, management of the baby and
his problem, and the post-delivery management of both of them at the
nursing home, demonstrated and settled in no uncertain terms that the
case put forth by Manmeet Singh Mattewal was not proved and
established. Once his case, as pleaded and projected, was not made
out, the NCDRC clearly erred in building up a new case on his behalf
23
and in pinning negligence and liability upon Dr. Kanwarjit Kochhar in the
context of antenatal care and management of the patient, which was
never the subject matter of the complaint case. In doing so, the NCDRC
overstepped its power and jurisdiction as it was not for it to travel beyond
the pleadings in the complaint case and build up a new case on its own
(See A.V.G.P. Chettiar & Sons and others vs. T. Palanisamy
9
Gounder , Venkataraman Krishnamurthy and another vs. Lodha
10
Crown Buildmart (P) Ltd. , Rama Kt. Barman (Died) Thr. LRs. vs.
11
Mohd. Mahim Ali and others ).
29. Useful reference may also be made to the observations of this
12
Court in Trojan and Company vs. Rm. N.N. Nagappa Chettiar , as
long back as in the year 1953, that it is well settled that the decision of a
case cannot be based on grounds outside the pleadings of the parties
and it is the case pleaded that has to be found. Again, in Ram Sarup
13
Gupta (Dead) by LRs vs. Bishun Narain Inter College and others ,
this Court observed that it is well settled that no party should be
permitted to travel beyond its pleadings and that all necessary and
material facts should be pleaded by a party in support of the case set up
by it. It was pointed out that the object and purpose of pleadings is to
enable the adversary party to know the case it has to meet as, in order
9
(2002) 5 SCC 337
10
(2024) 4 SCC 230
11
2024 SCC OnLine SC 4083
12
(1953) 1 SCC 456
13
(1987) 2 SCC 555
24
to have a fair trial, it is imperative that a party should settle the essential
material facts so that the other party may not be taken by surprise.
30. Viewed thus, the NCDRC clearly transgressed its jurisdiction in
building a new case for the complainants, contrary to their pleadings.
However, its finding that there was no negligence in the delivery and the
post-delivery treatment of Charanpreet Kaur have attained finality as no
separate appeal was preferred by the complainants. The impugned
order passed by the NCDRC, confirming the SCDRC’s judgment on the
new grounds made out by it, therefore, cannot be sustained.
31. The appeal is accordingly allowed, setting aside the order dated
09.05.2012 passed by the National Consumer Disputes Redressal
Commission, New Delhi, in First Appeal Nos. 158 and193 of 2007, as
well as the judgment dated 31.01.2007 passed by the State Consumer
Disputes Redressal Commission, Union Territory, Chandigarh, in
Complaint Case No. 56 of 2006. In consequence, the said complaint
case shall stand dismissed.
Manmeet Singh Mattewal, respondent No. 1, shall return and
refund the sum of 10,00,000/- received by him, pursuant to the orders ₹
passed in this litigation, to Dr. Kanwarjit Kochhar, Dr. GS Kochhar and
New India Assurance Company Ltd. in monthly instalments of
₹ 1,00,000/- each. The first three instalments, aggregating to
₹ 3,00,000/-, shall be paid to New India Assurance Company Ltd. and the
25
balance sum of 7,00,000/- shall be paid to Dr. Kanwarjit Kochhar and ₹
Dr. GS Kochhar under acknowledgement, as we are informed that the
nursing home is no longer in existence.
In the circumstances, parties shall bear their own costs.
……................................, J.
SANJAY KUMAR
……................................., J.
SATISH CHANDRA SHARMA
September 9, 2025
New Delhi.
26
2025 INSC 1094
IN THE SUPREME COURT OF INDIA
CIVIL APPELLATE JURISDICTION
CIVIL APPEAL NO. 1662 OF 2016
Deep Nursing Home and another … Appellants
Versus
Manmeet Singh Mattewal and others … Respondents
J U D G M E N T
SANJAY KUMAR, J
Manmeet Singh Mattewal, respondent No. 1, lost his wife,
Charanpreet Kaur, and his newborn son within the span of a few hours.
Shiraz Mattewal, respondent No.2, is his older son. Our sympathies
aside, we are called upon to examine the validity of the finding that
Dr. (Mrs.) Kanwarjit Kochhar, appellant No.2, the Obstetrician/
Gynaecologist who conducted the delivery is guilty of medical
negligence and deficiency in service. By judgment dated 31.01.2007 in
Complaint Case No. 56 of 2006, the State Consumer Disputes
Signature Not Verified
Digitally signed by
babita pandey
Date: 2025.09.09
18:03:47 IST
Reason:
1
Redressal Commission, Union Territory, Chandigarh , had found her and
1
for short, ‘the SCDRC’
1
Deep Nursing Home, Chandigarh, appellant No.1, medically negligent on
the ground that they did not exercise due care and caution in treating
Charanpreet Kaur but held that there was no fault on their part insofar as
the death of the newborn child was concerned. The SCDRC directed
them to pay 20,26,000/- to the complainants, Manmeet Singh Mattewal
₹
and Shiraz Mattewal. However, as they were covered by the insurance
policy issued by New India Assurance Company Limited, respondent No.
3 herein, the company was directed to pay 20,00,000/- and the balance ₹
was directed to be paid by them. Interest @ 9 % was awarded if the
amount was not paid in one month. Costs of 10,000/- ₹ were also
awarded.
2. Deep Nursing Home, Chandigarh, and Dr. Kanwarjit Kochhar filed
First Appeal No. 158 of 2007 before the National Consumer Disputes
2
Redressal Commission, New Delhi , assailing the SCDRC’s judgment.
First Appeal No. 193 of 2007 was filed separately by New India
Assurance Company Limited. However, by order dated 09.05.2012, the
NCDRC dismissed both appeals. Therein, the NCDRC came to the
conclusion that no liability would attach to Deep Nursing Home,
Chandigarh, and pinned the entire responsibility of paying 20,26,000/- ₹
upon Dr. Kanwarjit Kochhar. As 6,00,000/- had already been deposited ₹
pursuant to its order dated 12.04.2007 and was withdrawn by Manmeet
2
for short, ‘the NCDRC’
2
Singh Mattewal, the NCDRC directed her to pay the balance sum of
₹ 14,26,000/- in 6 weeks along with costs of 14,000/-. In the passing, ₹
we may note that the NCDRC reserved judgment in the appeals on
27.07.2010 but the order was pronounced by it nearly two years later, on
09.05.2012!
3. Despite the clean chit given to it by the NCDRC, Deep Nursing
Home, Chandigarh, joined Dr. Kanwarjit Kochhar in filing the special
leave petition from which the present appeal arises. By order dated
10.02.2014, this Court directed a further sum of 4,00,000/- to be paid to ₹
Manmeet Singh Mattewal and Shiraz Mattewal, respondent Nos. 1 and 2
herein. Leave was granted by this Court on 15.02.2016.
4. At the outset we may note that, in Universal Sompo General
3
Insurance Co. Ltd. vs. Suresh Chand Jain and another , this Court
affirmed that a special leave petition under Article 136 of the Constitution
is not the proper remedy against an appellate order passed by the
NCDRC. However, as this matter was entertained and has been pending
on the file of this Court for over twelve years, we do not think it proper to
relegate the appellants at this late stage to the alternative remedy under
Article 226 of the Constitution before the jurisdictional High Court.
5. We may now note the contents of Complaint Case No. 56 of 2006
filed before the SCDRC: Charanpreet Kaur, a co-operative bank
3
(2024) 9 SCC 148
3
manager on deputation as a lecturer in the Punjab Institute of
Cooperative Training, was aged about 32 years and was earning a
th
monthly salary of 25,682/-. She was in the 8 ₹ month of her pregnancy
when she started consulting Dr. Kanwarjit Kochhar of Deep Nursing
Home, Chandigarh. According to the complaint case, she visited the
nursing home several times and also underwent the tests prescribed
from time to time. Photocopies of the ultrasound tests done on
08.08.2005, 11.11.2005 and 16.12.2005 were filed in this regard. It was
stated that the couple visited the nursing home on 10.11.2005,
29.11.2005 and 09.12.2005 for check-ups and were assured that all was
well and that it would be a normal delivery. A copy of the prescription
dated 10.11.2005, with entries, was also filed. Charanpreet Kaur was
admitted on 21.12.2005 at about 11.00 AM for delivery. However, the
newborn child died instantly after birth, which took place at 02.00 AM on
the next day. It was alleged that the nursing home was ‘inadequately and
ill equipped’ to handle emergencies during deliveries and there were no
facilities available in that regard.
6. According to the averments made, the mother was informed about
the death of the newborn child which resulted in her going into shock
and caused profuse bleeding. It was alleged that no blood was readily
available in the nursing home for transfusion and the delay in shifting her
to the Post Graduate Institute of Medical Education and Research,
4
4
Chandigarh , at 05.30 AM resulted in her being declared ‘brought dead’
on arrival. It was further alleged that the staff of Deep Nursing Home did
not bring any reference papers or history sheet to facilitate her treatment
at the PGI. The van in which she was taken was also ill-equipped and it
was claimed that no doctor accompanied her in the said van. It was
alleged that Dr. GS Kochhar, the husband of Dr. Kanwarjit Kochhar, who
represented Deep Nursing Home, Chandigarh, chose to follow the van in
his car separately and, therefore, there was no qualified doctor in the
van.
7. Thus, the specific allegations levelled against the nursing home
and the doctor were that the nursing home was not equipped to handle
emergencies and complications during deliveries; the record of the
treatment was fabricated later to escape prosecution; the blood group of
Charanpreet Kaur was not checked and this led to delay in blood
transfusions; the death of the newborn child was also due to negligence;
there was negligence in causing trauma to Charanpreet Kaur by
informing her of the death of the newborn which resulted in shock and
bleeding; and the nursing home had no stock of blood readily available
for transfusion. The complainants sought compensation of 95,21,000/- ₹
along with interest @ 18% per annum, medical expenses of 10,000/- ₹
4
for short, ‘the PGI’
5
and litigation expenses of 11,000/-. This complaint case was filed on ₹
11.05.2006.
8. A lengthy written statement was filed by the opposite parties, viz .,
Deep Nursing Home and Dr. Kanwarjit Kochhar. Therein, they pointed
out that Manmeet Singh Mattewal had earlier reported the matter to the
Senior Superintendent of Police, Chandigarh, and an enquiry was
conducted by a Medical Board, consisting of experts, to ascertain
whether there was any medical negligence and the Board had negated
the same. It was stated that Charanpreet Kaur had suffered atonic Post
5
Partum Haemorrhage which proved to be catastrophic as she did not
respond to the treatment administered in the nursing home. It was stated
that PPH is a failure of the uterus to properly contract after the child is
born resulting in bleeding within the uterus, which cannot be controlled. It
was asserted that proper treatment was given as per protocol but
despite the same, she did not respond and ultimately died. Details were
given of the experience and expertise of Dr. Kanwarjit Kochhar and the
well-equipped status of the nursing home. It was stated that Dr. GS
Kochhar, who ran the nursing home, was a renowned anaesthetist.
Charanpreet Kaur was stated to have come to the nursing home on
10.11.2005 along with her mother and another person. Her date of
delivery was approximated to be around 02.01.2006. As she wanted to
5
for short, ‘PPH’
6
have her delivery at the nursing home with Dr. Kanwarjit Kochhar, she
was advised to continue with the intake of Iron and Calcium. It was
stated that Charanpreet Kaur did not show the reports of her earlier
check-ups, despite being asked by Dr. Kanwarjit Kochhar, and neither
did she show records of her previous delivery. It was further stated that
Dr. Kanwarjit Kochhar came to know from the hushed tones of
Charanpreet Kaur that there was some problem in the delivery of the first
child, but this was not divulged to her. She claimed that she later came
to know that the first child was autistic, but this was also not disclosed to
her. She asserted that, had this fact come to her knowledge earlier, she
might have refused to undertake the delivery, as there were more
chances of the second child having congenital abnormalities if the first
child had them.
9. The written statement then went on to state as follows:
Charanpreet Kaur’s check-ups were on 29.11.2005 and 09.12.2005. As
per their advice, Charanpreet Kaur had informed them that she had
consulted a cardiologist but she did not show any report thereof. Again,
on 16.12.2005, Charanpreet Kaur came for a routine check-up and was
advised to continue with her earlier medication. On 21.12.2005, at about
11.00 AM, Charanpreet Kaur was admitted in the nursing home as she
was suffering from back pain, but she was not in labour. Labour was
induced and she was making good progress. At about 01.00 AM on
7
22.12.2005, she was having strong contractions. Dr. RP Bansal, a
qualified paediatrician, was present with the patient from 02.15 AM
onwards. The delivery took place at 02.40 AM, but the newborn child did
not cry. The baby was handed over to the paediatrician for resuscitation
and oxygen was administered through a nasal tube. However, all efforts
to save the baby failed and he was declared dead at 03.10 AM. The
mother was not informed about the death of the baby. The near relations
were informed about it and were advised to get an autopsy done to
ascertain the exact cause of death of the child. However, they refused to
do so.
10. Details were furnished of the treatment given to Charanpreet Kaur
post-delivery and it was stated that there were no placental tissue or
membranes in her uterus. The cervix was also examined and no tear
was found. However, as there was still bleeding, her relations were
asked to secure two units of blood from the blood bank in Sector 37,
Chandigarh. Dr. GS Kochhar telephonically informed the blood bank to
keep the same ready without delay. Transfusion was commenced at
about 04.15 AM. Owing to the complications which had arisen, two more
doctors, viz ., a senior Gynaecologist and a General Surgeon were
contacted, and they reached the nursing home at 04.00 AM. All the
doctors present conducted a thorough examination and opined that the
patient was suffering from uterine inertia PPH and it was decided that
8
she should be sent to the PGI. The staff of the septic labour room at the
PGI were informed in advance to be ready to receive and treat her. She
was shifted in an ambulance with running blood transfusion and an
Ambu bag (oxygen). Two staff nurses from the nursing home
accompanied her while Dr. GS Kochhar went there in his own car. He
personally took the patient on a stretcher to the septic labour room. On
his request, completion of the other formalities prior to admission were
kept on hold. During the journey, the patient suffered a bout of bleeding
and was in deep shock. After reaching the PGI, she was examined but
no pulse and heart beat were palpable. Despite resuscitative measures,
she did not survive. The patient developed uterine inertia PPH which is a
disorder with poor prognosis and high mortality. Uterine Artery
Embolization facility was available only in the PGI in the whole of North
India. The blood group of Charanpreet Kaur was checked and the same
was written on the prescription dated 10.11.2005 itself, which had been
filed with the complaint. It was denied that the nursing home was ill-
equipped to handle emergencies during deliveries. It was asserted that
there was no delay in shifting the patient to the PGI.
11. No rejoinder was filed by the complainants to the above written
statement.
12. The SCDRC, vide its judgment dated 31.01.2007, found fault with
Dr. Kanwarjit Kochhar for not getting Charanpreet Kaur’s blood group
9
identified at the time of delivery and in arranging for transfusion by
keeping blood supply ready. Reference was made to a textbook on
Obstetrics and Gynaecology by the SCDRC and it was opined that, in a
case of PPH, excessive bleeding after child birth is the single largest
cause of maternal deaths worldwide. The SCDRC came to the
conclusion that the nursing home and Dr. Kanwarjit Kochhar wasted
almost two hours in getting blood and cross-matching it and this led to
deterioration of the patient’s condition. Examining the averments in the
written statement, the SCDRC found fault with Dr. GS Kochhar for not
accompanying the patient in the ambulance to the PGI. The SCDRC
went to the extent of doubting his very presence there. The conclusion
drawn by the SCDRC was that Charanpreet Kaur was already dead
when she was taken to the PGI and this was done only to dump her
dead body there. The affidavit filed by Dr. GS Kochhar was held to be
a false and fabricated document and the SCDRC categorically recorded
a finding that he did not go to the PGI. Reference was made to the
Report dated 18.08.2006 of the Medical Board at Government Medical
College and Hospital, Sector 32, Chandigarh, which opined that ‘there
did not appear any gross medical negligence in the management of the
patient by the treating doctors’ but the same was discarded on the
ground that it was a short report without reasons for recording such a
finding. The SCDRC held that it was certainly a case of negligence on
10
the part of the nursing home and Dr. Kanwarjit Kochhar and they had
failed to exercise due care and caution in treating Charanpreet Kaur,
even if it was presumed that there was no fault on their part insofar as
the death of the child was concerned. The SCDRC, accordingly, directed
payment of compensation as stated hereinabove.
13. In appeal, as demonstrated by the impugned order, the NCDRC
observed that Charanpreet Kaur’s death was investigated quite
thoroughly by successive Medical Boards, appointed specifically for that
purpose on complaints of gross negligence made by Manmeet Singh
Mattewal to various authorities of the State Government. Before the
NCDRC, it was stated on behalf of the appellants that the delivery was
complete only at about 03.00 AM after the patient expelled the placenta.
It was contended that in a normal delivery, as was the case here, the
uterus would gradually contract on its own after the delivery and the
bleeding would stop but, in this case, the uterus did not contract fully and
went into a phase of relaxation after the initial contraction. It was stated
that, the unusual nature of the bleeding could be known only after it was
verified that it was not from any tear in the vagina or the cervix or from
the site of the episiotomy and all this took some time, as detailed in the
medical record. It could be concluded only around 03.15 AM that the
uterus had not contracted. It was pointed out that, in the course of a
normal delivery, units of blood are not kept ready for transfusion and,
11
therefore, the assumption of the SCDRC, that there was delay and that
the time taken to get the blood was two hours, was factually incorrect. It
was asserted that the patient’s medical record showed that the
transfusion was started in less than an hour of the diagnosis of the
possible cause of bleeding, i.e., atonic uterus. It was also pointed out
that the SCDRC’s conclusion that the patient’s blood group was not
recorded was erroneous. The first page of the medical record showed
that the patient’s blood group was noted right at the beginning but before
starting blood transfusion, every unit of blood has to be necessarily
cross-matched with that of the patient, and this was done in the present
case also. It was asserted that there was no delay in shifting the patient
to the PGI and that all possible care was taken during that process. She
was accompanied by two nurses from the nursing home with a unit of
blood being transfused simultaneously on each arm along with oxygen
supply. Dr. GS Kochhar preceded the van in his car to ensure that there
was no delay in taking her to the septic labour room. It was pointed out
that five Medical Boards had examined the case record and concluded
that, neither in dealing with the newborn’s asphyxia nor in treating the
mother for the sudden complication of atonic PPH, Dr. Kanwarjit Kochhar
had committed any act of medical negligence. All the experts who
constituted these Boards found that there was no negligence on her part
or on the part of the nursing home.
12
14. The NCDRC dealt with each of the Medical Board Reports in turn,
viz ., the first Report dated 23.01.2006 by a Board of four doctors from
the Government Hospital, Sector 16, Chandigarh; the second Report
dated 20.03.2006 of a Board of five doctors from the Government
Medical College and Hospital, Sector 32, Chandigarh; the third Report
dated 03.04.2006 of the reconstituted Committee of four doctors from
the Government Medical College and Hospital, Sector 32, Chandigarh;
and the fourth Report dated 18.08.2006 of a Committee of seven doctors
constituted under the Chairmanship of the Director, Health Services,
Union Territory, Chandigarh. The undated fifth and final Report of four
doctors was also from the Government Medical College and Hospital,
Sector 32, Chandigarh, but it was not taken note of by the NCDRC.
15. The NCDRC, thereupon, looked into medical literature and
copiously extracted from such literature in its order. It noted that
Charanpreet Kaur was under the medical care of Dr. Kanwarjit Kochhar
nd
from the 32 week of her pregnancy through childbirth. It was noted that
she had gone to some other Obstetrician during the earlier part of her
second pregnancy. Noting the claim made by Dr. Kanwarjit Kochhar that
she was not told details of the delivery of the first child but her suspicion
that there was some problem therewith, the NCDRC observed that it was
the minimum professional requirement for her to have gathered such
information. The NCDRC also found fault with the medical record
13
maintained by the nursing home after Charanpreet Kaur’s first visit. It
was noted that Dr. Kanwarjit Kochhar had claimed that the prior medical
record was not given to her and the NCDRC opined that she had failed
to ascertain information which had crucial implications, i.e., with regard
to Charanpreet Kaur’s haematological status. We may observe, at this
stage, that the NCDRC seems to have visualized itself in the role of a
medical professional and expressed purported expert opinions on how
Dr. Kanwarjit Kochhar ought to have acted as an Obstetrician when
Charanpreet Kaur came to her initially and as to how she should have
gone about prescribing tests!
16. In effect, the NCDRC opined that, though all the Medical Boards
had opined that there did not appear to be any gross medical negligence
in the management of the patient by the treating doctors after the
delivery, the same did not mean that there was no medical negligence
before the delivery. As per the NCDRC, there were several instances of
departure from standard protocols in the antenatal care of the patient on
the part of Dr. Kanwarjit Kochhar as she failed to insist on the patient
getting standard haematological investigations done. According to the
NCDRC, no case of tortious medical negligence was made out against
Dr. Kanwarjit Kochhar in handling Charanpreet Kaur’s labour, including
the delivery, the management of the baby, the baby’s problem and the
post-delivery management at the nursing home, but there was enough
14
evidence as well as expert opinion to hold that antenatal management of
Charanpreet Kaur by Dr. Kanwarjit Kochhar, particularly, in respect of
necessary haematological and cardiological investigations, was not in
accordance with the standard protocols that an Obstetrician of average
skill would adopt. It further held that no case of medical negligence/
deficiency in service was made out against the nursing home as there
was nothing in the Medical Boards’ Reports on this aspect and the
complainants did not lead any reliable evidence in support of their
allegations in this regard. The NCDRC, therefore, concluded that no
liability could attach to the nursing home. The NCDRC noted that,
pursuant to its direction on 12.04.2007, Manmeet Singh Mattewal had
withdrawn ₹ 6,00,000/- deposited by the nursing home and the insurance
company and directed that the balance amount due be paid by Dr.
Kanwarjit Kochhar.
17. It would be apposite at this stage to note the contents of the
Medical Boards/Committees’ Reports. The first Report dated 23.01.2006
was furnished by the Board of doctors from Government Hospital, Sector
16, Chandigarh. This Board comprised Dr. Rupinder Kaur, Dr. Vidhu
Bhasin and Dr. N.K. Kaushal. After perusing the record, the Board
opined that the patient had died because of severe atonic PPH which did
not respond to the treatment given at the nursing home. It was recorded
that the treatment given was as recommended and that blood is not
15
arranged beforehand for normal deliveries. It was noted that the blood
samples were sent for cross-matching at 03.15 AM; that the patient went
into shock at 03.45 AM, that blood was brought from Rotary and Blood
Bank Society, Sector 37, Chandigarh; that blood transfusion was started
at 04.15 AM on both arms; and she was then referred to the PGI.
18. The second Report dated 20.03.2006 was from a Board of doctors
of Government Medical College and Hospital, Sector 32, Chandigarh.
The doctors in this Board were Professor Veena Parmar, HoD of
Paediatrics; Professor Anju Huria, HoD of Obstetrics & Gynaecology;
Professor K.K. Gombar, HoD of Anaesthesia; Professor A.K. Attri, HoD
of Surgery; and Professor Harsh Mohan, Medical Superintendent and
HoD of Pathology (Chairman). The conclusion of the Board was that the
patient had atonic PPH which was managed conservatively but without
success. It was noted that PPH is a known complication of delivery and
accounted for 8% of maternal mortality in developed countries. The
Board opined that different patients may cope differently with blood loss
in PPH - a healthy woman would be far more tolerant to blood loss of 30-
50% when compared to a woman with either pre-existing anaemia or
underlying cardiac complications or pre-eclampsia. The Board opined
that it could not be said with certainty from the record whether this
patient had anaemia or hypotension and shock before delivery but in the
presence of either or both of these conditions, atonic PPH was more
16
likely to be catastrophic. This final conclusion of the Board did not indict
Dr. Kanwarjit Kochhar but left the question open as it was not clear from
the record whether the patient had any of these conditions before the
delivery.
19. The third Report dated 03.04.2006 was submitted by a Committee
of doctors from the Government Medical College and Hospital, Sector
32, Chandigarh, comprising Professor A.K. Attri, HoD of Surgery
(Chairman); Dr. Satinder Gombar, Professor and HoD of Anaesthesia;
Dr. Anju Huria, HoD of Obstetrics & Gynaecology; and Dr. Suksham
Jain, Assistant Professor of Paediatrics. This Committee, after perusing
the record submitted by the Office of the Director, Health and Welfare,
Chandigarh Administration, discussed the previous reports submitted by
the teams of doctors from the General Hospital, Sector 16, Chandigarh,
and the Government Medial College and Hospital, Sector 32,
Chandigarh, and upon perusal of the medical record and the medical
reports and after thorough deliberations, the Committee opined that
there was no gross medical negligence in the management of the
patient.
20. The fourth Report from the Government Medical College and
Hospital, Sector 32, Chandigarh was dated 18.08.2006. This report was
consequential to the letter dated 15.06.2006 of the Senior
Superintendent of Police, Union Territory, Chandigarh. This Committee
17
consisted of Dr. Manjit Singh Bains, Director, Health Services, General
Hospital, Sector 16, Chandigarh (Chairman); Dr. Usha Bishnoi, Medical
Superintendent, General Hospital, Chandigarh; Professor Harsh Mohan,
Medical Superintendent, Government Medical College and Hospital,
Sector 32, Chandigarh; Professor K.K. Gombar, HoD of Anaesthesia;
Professor Veena Parmar, HoD of Paediatrics; Professor Anju Huria, HoD
of Gynaecology.; and Dr. A.K. Attri, HoD of Surgery. The Committee
deliberated on the issue addressed in the letter and considered the
records of the deceased mother and child provided by the police
department. The Committee also discussed the reports submitted
previously by the teams of doctors from the General Hospital, Sector 16,
Chandigarh, and the Government Medical College and Hospital, Sector
32, Chandigarh. After considering the said records and reports, the
Committee opined that there did not appear to be any gross medical
negligence in the management of the patients by the treating doctors.
21. The fifth and final undated Report was also from the Government
Medical College and Hospital, Sector 32, Chandigarh. This Committee
comprised Professor A.K. Attri, HoD of Surgery (Chairman); Dr. Satinder
Gombar, Professor and HoD of Anaesthesia; Dr. Anju Huria, HoD of
Obstetrics and Gynaecology; and Dr. Suksham Jain, Assistant Professor
of Paediatrics. The Committee perused the whole record submitted by
the Office of the Director, Health and Welfare, Chandigarh
18
Administration, and discussed the previous reports submitted by the
teams of doctors. After thorough deliberations and perusal of the medical
records and the reports, the Committee opined that there was no gross
medical negligence in the management of the patients.
22. Significantly, all the above reports came about upon the instigation
and at the behest of Manmeet Singh Mattewal himself, who seems to
have approached various authorities voicing his grievance against Dr.
Kanwarjit Kochhar and the nursing home in relation to the death of his
wife and child. However, except for one report which, owing to lack of
sufficient data, left one question open, i.e., the possible pre-existing
conditions that may have led to the death of Charanpreet Kaur, none of
the reports held Dr. Kanwarjit Kochhar negligent. Further, given the
settled legal position that every failure in the treatment of a patient does
not automatically lead to an assumption of medical negligence, we find
that the opinions expressed by the doctors and experts, who constituted
these Medical Boards/Committees, clearly tilted the balance in favour of
Dr. Kanwarjit Kochhar, as none of them found any medical negligence
on her part. As already noted hereinbefore, these bodies were
constituted at the behest of Manmeet Singh Mattewal himself and he
cannot, therefore, fight shy of the conclusions and findings rendered by
them.
19
23. As pointed out in Jacob Mathew vs. State of Punjab and
6
another , simply because a patient did not favourably respond to the
treatment given by a physician or if a surgery failed, the doctor cannot be
held liable per se by applying the doctrine of res ipsa loquitur. This edict
7
was reiterated in Martin F. D'Souza vs. Mohd. Ishfaq wherein, it was
pointed out that no sensible professional would intentionally commit an
act or omission which would result in harm or injury to a patient as the
reputation of that professional would be at stake and a single failure may
cost him or her dear in that lapse. It was also pointed out that
sometimes, despite best efforts, the treatment by a doctor may fail but
that does not mean that the doctor or surgeon must be held guilty of
medical negligence, unless there is some strong evidence to suggest
that he or she is. It was also pointed out that Courts and Consumer Fora
are not experts in medical science and must not substitute their own
views over that of specialists. While acknowledging that the medical
profession had been commercialised to some extent and there were
doctors who depart from their Hippocratic Oath for their selfish ends of
making money, this Court held that the entire medical fraternity cannot
be blamed or branded as lacking in integrity or competence just because
of some bad apples.
6
(2005) 6 SCC 1
7
(2009) 3 SCC 1
20
24. On the same lines, in Devarakonda Surya Sesha Mani and
8
others vs. Care Hospital, Institute of Medical Sciences and others ,
it was held that unless a complainant is able to establish a specific
course of conduct, suggesting a lack of due medical attention and care,
it would not be possible for the Court to second-guess the medical
judgment of the doctor on the line of treatment which was administered
and, in the absence of such material disclosing medical negligence, the
Court cannot form a view at variance, as every death in the
institutionalised environment of a hospital does not necessarily amount
to medical negligence on a hypothetical assumption of lack of due
medical care.
25. In any event, the NCDRC’s ultimate conclusion was that there was
negligence on the part of Dr. Kanwarjit Kochhar only in the antenatal
care and management of Charanpreet Kaur. More importantly, the
NCDRC rendered a clear finding that there was no medical negligence in
the handling of Charanpreet Kaur’s labour, including her delivery; the
management of the baby’s problem; and the post-delivery management
at the nursing home. These conclusions, arrived at by the NCDRC, not
only reversed the findings of the SCDRC but also turned the very case
put forth by the complainants on its head. In fact, the NCDRC decided
the matter by building up a new case altogether!
8
2022 SCC OnLine SC 1608
21
26. The specific claim of Manmeet Singh Mattewal in Complaint Case
No. 56 of 2006 was that there was medical negligence on the part of
Dr. Kanwarjit Kochhar and the nursing home in the post-delivery
treatment only, as sufficient facilities were not available in the nursing
home to deal with post-delivery emergencies, and Dr. Kanwarjit Kochhar
failed to take adequate care and caution after the delivery to save the life
of the patient. He categorically asserted that the nursing home was
‘inadequately and ill equipped’ to handle emergencies during deliveries
and there were no facilities available in that regard. His further allegation
was that Charanpreet Kaur was informed about the death of the
newborn child which resulted in her going into shock and caused profuse
bleeding. However, this was not proved and neither the SCDRC nor the
NCDRC recorded a finding on this aspect. His further allegation was that
there was delay in arranging for blood transfusions and there was
negligence during the transfer of Charanpreet Kaur from the nursing
home to the PGI. He made no allegations whatsoever to the effect that
the antenatal care and management of Charanpreet Kaur were deficient
in any manner. On the contrary, he specifically asserted that various
tests were prescribed by Dr. Kanwarjit Kochhar and Charanpreet Kaur
underwent all such tests.
27. The SCDRC had accepted Manmeet Singh Mattewal’s case and
held that negligence was attributable to Dr. Kanwarjit Kochhar and the
22
nursing home in relation to the post-delivery care and treatment of
Charanpreet Kaur. However, this finding was reversed by the NCDRC,
as is evident from the impugned order, wherein the NCDRC held in clear
terms that no liability attached to the nursing home and it was Dr.
Kanwarjit Kochhar who was to be held responsible on the ground of
medical negligence in the antenatal care and management. The specific
finding of the NCDRC was that Dr. Kanwarjit Kochhar had not prescribed
the requisite haematological tests for Charanpreet Kaur.
28. This was never the case of Manmeet Singh Mattewal. The entire
focus of the NCDRC, however, was only upon the antenatal care and
management of the patient and its pinpointed findings were also in
relation to the said period and treatment only. The NCDRC’s observation
that there were several instances of departure from standard protocols in
the antenatal management of the patient, such as, not getting proper
tests done, and its final finding that no case of tortious medical
negligence was made out against Dr. Kanwarjit Kochhar in handling
Charanpreet Kaur’s labour, her delivery, management of the baby and
his problem, and the post-delivery management of both of them at the
nursing home, demonstrated and settled in no uncertain terms that the
case put forth by Manmeet Singh Mattewal was not proved and
established. Once his case, as pleaded and projected, was not made
out, the NCDRC clearly erred in building up a new case on his behalf
23
and in pinning negligence and liability upon Dr. Kanwarjit Kochhar in the
context of antenatal care and management of the patient, which was
never the subject matter of the complaint case. In doing so, the NCDRC
overstepped its power and jurisdiction as it was not for it to travel beyond
the pleadings in the complaint case and build up a new case on its own
(See A.V.G.P. Chettiar & Sons and others vs. T. Palanisamy
9
Gounder , Venkataraman Krishnamurthy and another vs. Lodha
10
Crown Buildmart (P) Ltd. , Rama Kt. Barman (Died) Thr. LRs. vs.
11
Mohd. Mahim Ali and others ).
29. Useful reference may also be made to the observations of this
12
Court in Trojan and Company vs. Rm. N.N. Nagappa Chettiar , as
long back as in the year 1953, that it is well settled that the decision of a
case cannot be based on grounds outside the pleadings of the parties
and it is the case pleaded that has to be found. Again, in Ram Sarup
13
Gupta (Dead) by LRs vs. Bishun Narain Inter College and others ,
this Court observed that it is well settled that no party should be
permitted to travel beyond its pleadings and that all necessary and
material facts should be pleaded by a party in support of the case set up
by it. It was pointed out that the object and purpose of pleadings is to
enable the adversary party to know the case it has to meet as, in order
9
(2002) 5 SCC 337
10
(2024) 4 SCC 230
11
2024 SCC OnLine SC 4083
12
(1953) 1 SCC 456
13
(1987) 2 SCC 555
24
to have a fair trial, it is imperative that a party should settle the essential
material facts so that the other party may not be taken by surprise.
30. Viewed thus, the NCDRC clearly transgressed its jurisdiction in
building a new case for the complainants, contrary to their pleadings.
However, its finding that there was no negligence in the delivery and the
post-delivery treatment of Charanpreet Kaur have attained finality as no
separate appeal was preferred by the complainants. The impugned
order passed by the NCDRC, confirming the SCDRC’s judgment on the
new grounds made out by it, therefore, cannot be sustained.
31. The appeal is accordingly allowed, setting aside the order dated
09.05.2012 passed by the National Consumer Disputes Redressal
Commission, New Delhi, in First Appeal Nos. 158 and193 of 2007, as
well as the judgment dated 31.01.2007 passed by the State Consumer
Disputes Redressal Commission, Union Territory, Chandigarh, in
Complaint Case No. 56 of 2006. In consequence, the said complaint
case shall stand dismissed.
Manmeet Singh Mattewal, respondent No. 1, shall return and
refund the sum of 10,00,000/- received by him, pursuant to the orders ₹
passed in this litigation, to Dr. Kanwarjit Kochhar, Dr. GS Kochhar and
New India Assurance Company Ltd. in monthly instalments of
₹ 1,00,000/- each. The first three instalments, aggregating to
₹ 3,00,000/-, shall be paid to New India Assurance Company Ltd. and the
25
balance sum of 7,00,000/- shall be paid to Dr. Kanwarjit Kochhar and ₹
Dr. GS Kochhar under acknowledgement, as we are informed that the
nursing home is no longer in existence.
In the circumstances, parties shall bear their own costs.
……................................, J.
SANJAY KUMAR
……................................., J.
SATISH CHANDRA SHARMA
September 9, 2025
New Delhi.
26