2021 INSC 0400
                            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.
1. The   appellants   in   all   the   above   three   appeals   are
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
herein guilty of medical negligence and has directed payment
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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.
2. The brief factual matrix leading to the above case is as
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. 
3. Accordingly,   the   patient   admitted   herself   on
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. 
4. The   second   surgery   was   prepared   to   be   conducted   on
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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5. The appellants contend that an issue arose with regard
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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7. The   appellants   herein,   who   were   the   respondents
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
F.D’Souza   vs.   Mohd.   Ishfaq   (2009)   3   SCC   1   wherein   it   is
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. 
13. In   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   Jacob   Mathew   (supra).   The
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.
14. Having   noted   the  decisions   relied  upon   by   the   learned
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. 
16. The   next   aspect   on   which   the   NCDRC   has   found   fault
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
Page  17  of  27

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
Page  19  of  27

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.
19. On   the   principle   of   res   ipsa   loquitur,   the   NCDRC   has
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,
Page  21  of  27

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
Page  22  of  27

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.
21. In   addition   to   what   has   been   noted   above,   in   the
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.
23. In the above circumstance when there was no medical
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.  
24. For   the   aforesaid  reasons,  the   order   dated   13.08.2009
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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