Supreme Court: To Hold Medical Practitioner Liable For Negligence, Higher Threshold Limit Must Be Met

Supreme Court: To Hold Medical Practitioner Liable For Negligence, Higher Threshold Limit Must Be Met

It was hearing a set of medical negligence-related appeals filed under the Consumer Protection Act

The Supreme Court has observed that to hold a medical practitioner liable for negligence, a higher threshold limit must be met.

A bench of Justice Hrishikesh Roy and Justice Manoj Misra stated that this would ensure that the doctors focused on deciding the best course of treatment as per their assessment rather than being concerned about possible persecution or harassment they might be subjected to in high-risk medical situations.

The bench held, “To safeguard these medical practitioners and to ensure that they can freely discharge their medical duty, a higher proof of burden must be fulfilled by the complainant. The complainant should be able to prove a breach of duty and the subsequent injury being attributable to the aforesaid breach to hold a doctor liable for medical negligence.”

The Court was hearing a set of medical negligence-related appeals filed under the Consumer Protection Act, 1986, assailing the impugned decision passed on 16 February 2018, by the National Consumer Disputes Redressal Commission (NCDRC) in a case filed by an individual Sunita Parvate.

Sunita alleged that due to medical negligence at the Suretech Hospital and Research Centre Private Limited in Nagpur, Maharashtra, she suffered permanent voice loss and damage to her respiratory tract. She accused the hospital of carrying out an unnecessarily and forcefully conducted Nasotracheal Intubation (NI) procedure, despite multiple failures in decannulating the TT.

(NI procedure entails inserting an endotracheal tube through the patient’s nose, to assist in breathing).

The NCDRC had directed the hospital, Dr. Nirmal Jaiswal (chief consultant, and intensive care unit in-charge), Dr. Madhusudan Shendre (ENT surgeon), and Dr. M. A. Biviji (radiologist), to jointly and severally pay Rs.6,11,638 to Sunita as compensation.

The medical negligence was proved on account of the unjustifiable and forceful performance of the NI procedure on Sunita on 13 May 2004, at Suretech Hospital.

However, the Supreme Court was approached with three appeals. One was filed by Dr. Biviji denying any role in the alleged medical negligence during Sunita’s treatment. The second by Suretech Hospital and other doctors denying that any negligence happened during her treatment. The third by Sunita seeking enhancement of compensation.

The Top Court observed that the medical team at Suretech Hospital had successfully proved that due medical consideration was given before choosing the NI procedure. Thus, no negligence was committed in opting for and/or conducting the procedure.

The judges were dealing with the issue of whether conducting the NI procedure and removing the existing TT after the bronchoscopy report indicated normalcy in Sunita’s airways, and did it amount to negligence.

The bench referred to the landmark judgment in the Jacob Mathew vs. State of Punjab, (2005) 6 SCC 1 and Kusum Sharma vs. Batra Hospital (2010) 3 SCC 480 case.

The Court cited three essential ingredients in determining an act of medical negligence.

1. Duty of care extended to the complainant.

2. Breach of the duty of care.

3. The resulting damage, injury, or harm caused to the complainant was attributable to the breach of duty. However, a medical practitioner would be held liable for negligence only in circumstances when his conduct fell below the standards of a reasonably competent practitioner.

The bench further explained that due to the unique circumstances and complications that arise in different individual cases, coupled with the constant advancement in the medical field and its practices, it was natural that there would always be different opinions, including contesting views regarding the chosen line of treatment, or the course of action to be undertaken.

In such circumstances, just because a doctor opts for a particular line of treatment but does not achieve the desired result, he cannot be held liable for negligence, provided that the said course of action undertaken was recognized as sound and relevant medical practice. This may include a procedure entailing a higher risk element, opted for after due consideration and deliberation by the doctor. Therefore, a line of treatment undertaken should not be of a discarded or obsolete category in any circumstance.

While addressing the impugned judgment, the bench observed that though it held that the NI procedure amounted to negligence, it failed to point towards the specific breach of responsibility.

It added that the NCDRC judgment did not indicate who performed the procedure. NI was a short-term procedure undertaken to assist in respiration whereas the TT was resorted to with the objective of providing a longer assisted respiration.

The judges said that NCDRC opined that replacing the existing TT with NI made little sense, particularly when Sunita was able to breathe normally through the TT.

The Apex Court highlighted that the tribunal failed to appreciate the medical projection that there was a need to remove TT because Sunita responded well to the treatment. To enable the patient’s return towards normalcy i.e., to breathe without assistance, it was necessary to remove the TT.

The bench held, “In fact, there was a potential risk of infection and development of complications like stenosis from long-term TT intubation.”

The Court also dwelled on the detailed analysis and examined the expert medical report of RML Hospital. It stated that after the difficulties faced during the TT decannulation process and the discovery of stridor, opting for the NI procedure as an alternative course of treatment to aid respiration could be medically justified.

The bench said, “As an accepted medical course of action, it was expected that the procedure would aid with recovery and lead to the desired results which did not happen. However, that cannot be said to be a breach of duty amounting to negligence. As was rightly observed in the Jacob Mathew case and Kusum Sharma case, adopting an alternative medical course of action would not amount to medical negligence.”

Justice Roy and Justice Misra stated that the burden of establishing negligence was on the complainant. However, Sunita had failed to prove medical negligence by the doctors. There was no evidence to establish that the NI procedure was a bad medical practice or based on unsound medical advice.

On the other hand, the medical team at Suretech Hospital had proved that due medical consideration was given before choosing the NI procedure.

The Court thus held that no negligence was committed in opting for and/or conducting the aforesaid procedure. The Court also stressed that the existing TT was removed after the bronchoscopy showed normalcy in the airways and trachea of the patient. It was expected that the patient would be able to breathe normally without any support after TT decannulation. However, a stridor was observed in the airways after the decannulation took place.

Considering the same, an alternative course of treatment in the form of an NI procedure was opted for as a temporary measure. There was nothing to show that the procedure conducted was outdated or poor medical practice.

The bench quoted renowned author and surgeon Dr. Atul Gawande on medical treatment, “We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible iividuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do.”

Thus, the Court allowed the appeals of the doctors and held that it was a classic case of human fallibility where the doctors tried to do the best for the patient as per their expertise and emerging situations. However, the desired results could not be achieved. So, it cannot be termed as a medical negligence case.