Kumar Ganguly Vs. Sukumar Mukherjee & Ors.  INSC 1410 (7 August 2009)
SUPREME COURT OF INDIA CRIMINAL APPELLATE JURISDICTION CRIMINAL APPEAL NOS.
1191-1194 OF 2005 Malay Kumar Ganguly ... Appellant Versus Dr. Sukumar
Mukherjee and others ....Respondents WITH CIVIL APPELLATE JURISDICTION CIVIL
APPEAL NO. 1727 OF 2007 Dr. Kunal Saha ... Appellant Versus Dr. Sukumar
Mukherjee and others ...Respondents
patient (Anuradha) and her husband Dr. Kunal Saha (for short,
"Kunal") were settled in the United States of America. Anuradha, a
child 2 Psychologist by profession, was a recent graduate from a prestigious
Ivy League School (`Columbia University' in the New York State). Although a
doctor by profession, Kunal has been engaged in research on H.I.V/ AIDS for the
past 15 years.
U.S.A. for a vacation to India on 24th March, 1998. They arrived in Calcutta on
1st April, 1998. While in Calcutta, Anuradha developed fever along with skin
rash on 25th April, 1998. On 26th April, Dr.
Mukherjee, Respondent No. 1 herein attended and examined Anuradha at her
parental residence on a professional call. Dr. Mukherjee assured the patient
and her husband of a quick recovery and advised her to take rest but did not
prescribe her any specific medicine. However, two weeks thereafter, i.e., on
7th May, 1998, the skin rash reappeared more aggressively. Dr. Mukherjee was
again contacted and as per his instructions, Anuradha was taken to his chamber.
After examining Anuradha, Dr.
prescribed Depomedrol injection 80 mg twice daily for the next three days.
Despite administration of the said injection twice daily, Anuradha's condition
deteriorated rapidly from bad to worse over the next few days. Accordingly, she
was admitted at the Advanced Medicare Research Institute (AMRI) in the morning
of 11th May, 1998 under Dr. Mukherjee's supervision. Anuradha was also examined
by Dr. Baidyanath 3 Halder, Respondent No. 2 herein. Dr. Halder found that she
had been suffering from Erithima plus blisters. Her condition, however,
continued to deteriorate further. Dr. Abani Roy Chowdhury, Consultant,
Respondent No. 3 was also consulted on 12th May, 1998.
about 17th May, 1998, Anuradha was shifted to Breach Candy Hospital, Mumbai as
her condition further deteriorated severely. She breathed her last on 28th May,
sent a lawyer's notice to 26 persons on 30th September, 1998.
19 addressees were those who had treated Anuradha at Kolkata while addressee
numbers 20 to 26 were those who treated her in Mumbai.
about 19th November, 1998 one of his relatives, Malay Kumar Ganguly filed a
Criminal Complaint in the Court of Chief Judicial Magistrate, 24 Paraganas at
Alipore against Dr. Sukumar Mukherjee, Dr.
Halder and Dr. Abani Roy Chowdhury, respondent Nos. 1, 2 and 3 for commission
of offence under Section 304-A of the Indian Penal Code.
Kunal filed O.P. Nos. 240 of 1999 against 19 persons who had rendered medical
advice/treatment/facilities to Anuradha between 23rd April, 1998 and 17th May,
1998 at Kolkata before the National Consumer Disputes Redressal Commission, New
Delhi (Commission). However, 4 pursuant to the orders of the Commission names of
some of the respondents were struck off.
said petition the complainant claimed an amount of compensation of Rs.
77,76,73,500/- with interest for the alleged deficiency in the service rendered
by Respondent Nos. 1, 2, 3, 5, 6 and AMRI hospital (Respondent No.4).
about 17.7.1999, a complaint was filed by Kunal against Dr. Sukumar Mukherjee,
Dr. Baidyanath Halder and Dr. Abani Roy Chowdhury before the West Bengal
Medical Council (WBMC) making allegations similar to the one he had made in his
complaint before the Commission.
about 29th May, 2000 , OP No. 179 of 2000 was filed by Kunal against the
doctors, including Dr. Udwadia of the Breach Candy Hospital at Mumbai and the
hospital itself before the Commission.
the learned Chief Judicial Magistrate, in the said criminal complaint a large
number of witnesses were examined. A large number of documents were also marked
as exhibits. The learned Chief Judicial Magistrate, Alipore by his judgment and
order dated 29th May, 2002 found Respondent Nos. 1 and 2 guilty of commission
of an offence under Section 5 304-A of the Indian Penal Code and sentenced them
to undergo simple imprisonment for three months and to pay a fine of Rs.3,000/-
each and in default to undergo a further simple imprisonment for 15 days.
Respondent No.3, Dr. Abani Roy Chowdhury was, however, acquitted.
Bengal Medical Council dismissed the complaint filed by Dr. Kunal by its order
dated 1st July, 2002.
May, 2003 the complainant-Kunal withdrew O.P. No.179/2009 filed before the
Commission against the doctors/Breach Candy Hospital.
the order of the learned Magistrate, Respondent No.1 filed Criminal Appeal
which was marked as Criminal Appeal No.55 of 2002 and Respondent No.2 filed
Criminal Appeal No. 54 of 2002 before the learned Sessions Judge at Alipore,
whereas the complainant, Mr. Malay Kumar Ganguly, filed a revision application
being C.R.R. No. 1856 of 2002 for enhancement of the punishment imposed on
Respondent Nos. 1 and 2. The complainant also filed another revision
application before the High Court questioning the legality of the judgment with
respect to acquittal of Respondent No.3. The Calcutta High Court withdrew the
appeals preferred 6 by Respondent Nos. 1 and 2 before the learned Sessions
Judge to itself and heard the criminal appeals and revision petitions together.
judgment and order dated 19th March, 2004 the appeals preferred by Respondent
Nos. 1 and 2 were allowed while the Criminal Revision Petitions filed by the
complainant were dismissed. The said order has been challenged before us by way
of Criminal Appeal Nos. 1191-1194 of 2005.
Commission also by its judgment and order dated 1st June, 2006 dismissed O.P.
No. 240 of 1999. Civil Appeal No.1727 of 2007 arises out of the said order.
SUBMISSIONS OF APPELLANT:
Saha, who appeared in person, made the following submissions :- (i) Respondent
No.1 from the very beginning should have referred Anuradha to a Dermatologist
as she had skin rashes all over her body.
Diagnosis of Respondent No.1 that Anuradha was suffering from angioneurotic
oedema with allergic vasculitis was wrong.
event, prescribing a long acting corticosteroid 7 `Depomedrol' injection at a
dose of 80 mg. twice daily for the next three days when it was the beginning of
angeioneurotic oedema and the continued treatment on the same line later at
AMRI by Respondent No.1 and other doctors led to her death inasmuch as - (a)
The Medical Journals as also the experts' opinion show that although steroid is
not to be used when the patient is diagnosed to be suffering from Toxic
Epidermal Necrolysis (TEN), and although some doctors still administer
steroids, the administering of Depomedrol of 80 mg. twice daily, could not be
prescribed under any clinical condition.
the said purpose the evidence of Dr. Anil Shinde (PW-8), Manager of Medical
Service for Pharmacia; Dr. S. Bhattacharyya (PW-11), a highly respected
Professor of Pharmacology at the Banaras Hindu University and opinions of Prof.
Jo-David Fine ; Professor Gerald Pierard and Prof. Fritsch Peter (Exts. 4, 5
and 6) opining that steroids and in any event Depomedrol could not be 8
prescribed; far less, in the quantity in which it had been done.
pro-steroid experts also only use "quick acting" steroids for a short
period and that too at very early stages of the disease and then quickly stop
the same to avoid its side effects to enhance the infection or taper it
Respondents failed to adhere to the treatment protocol as outlined in the Table
of the Textbook "Cutaneous Medicine and Surgery" authored by Prof.
J.E. Revuz and J.C. Rojeau recommending - 5 "Primary Emergency Care"
and "Symphtomatic Therapy" including specific direction for
"fluid replacement', "antibacterial policy", "nutritional
aforementioned should have been advised for treatment of Anuradha at AMRI.
treatment given to Anuradha at AMRI hospital continued as Respondent Nos. 2 and
3 jointly took charge and recommended steroids, despite stopping
"'Depomedrol' after 12th May, 1998 without realizing that she had already
been a huge amount of a "long-acting" steroid (Depomedrol) and in 9
that view of the matter they should have administered adopted remedial measures
which was not done.
Respondents Nos.2 and 3 added more fuel to the fire in the form of a new
"quick-acting" steroid, "Prednisolone" at 40 mg.
times daily, which was itself an excessive dose. Dr. Udwadia of Breach Candy
Hospital noticed the same when Anuradha was examined by him; as according to
him not more than 40 mg. Prednisolone daily for one day, to be reduced to 5 mg.
within the next 5 to 6 days is the ideal dosage.
When a patient is diagnosed to be suffering from TEN, supportive therapy is
imperative in character but no such advice was rendered.
and after 12th May, 1998, Anuradha was not provided any supportive treatment
which could be evident from the hospital records seized by the police.
Although the police seized 71 pages of the record from AMRI, merely 22 pages
are in relation to her stay during 11th May to 17th May, 1998, whereas the
medical record of Breach Candy Hospital from 17th May to 27th May, 1998 cover
around 370 pages.
10 (x) At
AMRI records of vital parameters like temperature, pulse, blood pressure; etc.
were not maintained which itself is an act of gross negligence.
Respondent Nos. 5 and 6, although were junior doctors, also followed the
treatment guidelines set forth by the three seniors doctors, even though they
were independent physicians with postgraduate medical qualifications and, thus,
it was expected of them that they would take their independent decisions.
Expert doctors has categorically stated that mal-practice had been committed
during the treatment of Anuradha.
The High Court committed a serious error in opining that there was no medical
negligence on the part of Respondents.
allegation that the appellant had resorted to forgery was arrived at by the
High Court without any application of mind as Dr. Anil Kumar Gupta testified
that it was Respondent No.5 who had inserted the words "for better
treatment" in his presence, which was also supported by Mr. T.R. Nehra,
transfer certificate when issued, in any event, must be held to be `for better
treatment" as otherwise transfer of a patient 11 from one hospital to the
other, in the situation of the present case, was not necessary.
claim that the appellant had interfered in the treatment and had been
responsible for his wife's death is absolutely incorrect inasmuch as his name
did not even appear in any of the hospital records suggestive of any
The alleged defence of alibi resorted to by Respondent No.3 and accepted by the
High Court is not borne out from the record which clearly shows that he was
closely involved in the treatment of Anuradha at AMRI.
The telephone bills brought on record clearly show that numerous calls were
made by Dr. Kunal Saha to Respondent No.3's residence as well as to his office,
during Anuradha's stay at AMRI which clearly established that Respondent No.3
was involved with Anuradha's treatment.
High Court has failed to consider the previous decisions of this Court on
criminal negligence, as in the instant case gross negligence on the part of the
Respondents establishes the offence committed by them under Section 304-A of
the Indian Penal Code.
Negligence in fact in Anuradha's treatment had been admitted by the Respondents
at different stages of the proceedings.
Kailash Vasdev, learned senior counsel appearing for Respondent Nos. 1 and 2
would submit :- (i) Kunal misled the doctors from time to time on the
drugs/treatment to be administered to Anuradha.
Pathological Reports which were carried out on the basis of the prescription of
Respondent No.1 had never been shown to him.
panel of elected Committee of the West Bengal Medical Council being an Expert
Body having come to a specific finding vis-`-vis the Respondents that there had
been no deficiency or negligence on the part of the doctors and use of the
drugs is demonstrative of the fact that Respondents had not committed an
offence under Section 304-A of the Indian Penal Code.
Ranjan Mukherjee, learned counsel appearing on behalf of Respondent No.3
contended :- (i) It stands admitted by the appellant during his
cross-examination that Respondent No.3 came to AMRI on 12th May, 1998 hours
after Dr. B.N. Halder came there.
There is no evidence that Dr. B.N. Halder and Respondent No.3 were together at
AMRI or that those they discussed about the treatment to be given to the
B.N. Halder in his examination under Section 313 of the Code of Criminal
Procedure has admitted that the prescription was written by him and, therefore,
Respondent No.3 cannot be said to have any liability.
plea of the appellant that a joint prescription was made by Respondent Nos. 2
and 3 having been found to be in the handwriting of Kunal himself must be held
to be a self-serving document.
from making the joint prescription, Respondent No.3 having not been involved in
the treatment of the deceased, the prosecution has miserably failed to prove
So far as the certificate of transfer of the patient is concerned, the same
admittedly being interpolated, no credence thereto can be attached.
no witness has testified in support of the allegation that he was the principal
physician of Anuradha during her stay at AMRI, the courts below must have
Respondent No.3 having been acquitted by both the courts, this Court should not
exercise its jurisdiction under Article 136 of the Constitution of India as the
view taken by the courts below is a plausible one.
PROCEEDINGS B.1. TRIAL COURT PROCEEDINGS The common defence of all the
Respondents in the case is denial of material allegations brought against them
as also false implication. Separate defences, however, have been entered into
by each of the Respondents. We would notice them in seriatum:
Sukumar Mukherjee examined Anuradha Saha (deceased) only on 7th May, 1998 and
11th May, 1998. He left India on 11th May, 1998 which was within the knowledge
of her husband. He treated 15 Anuradha as per medical protocol. He diagnosed
her disease as allergic/hypersensitivity vasculitis. Depomedrol was correctly
prescribed, being required for the disease Anuradha had been suffering from.
The dose prescribed was also correct. He prescribed certain tests to be taken
on 7th May as also on 11th May but he was not apprised of the results of those
tests. On 11th May, he had also prescribed the requisite supportive treatment
which was necessary for the recovery of Anuradha.
Baidyanath Halder examined the patient for one day only on 12th May, 1998. He
diagnosed the disease as Toxic Epidermal Necrolysis (TEN) correctly and
prescribed medicines as per the treatment protocol noted in the text books. He
examined the patient having been requested by a group of his students who were
friends of Anuradha's husband. He did not charge any fees. He prescribed all
necessary supportive therapy required for the patient of TEN. He had not been
given any feedback by the husband of the deceased after 12th May, 1998.
Abani Roychowdhury had never seen the patient nor treated her at AMRI at any
point of time. He being attached to AMRI visited the hospital once in a week at
the outdoor. On 12th May, 1998 having 16 been requested by Dr. Kunal Saha as
also Dr. Prasad, he went to the cabin only for the purpose of boosting the
patient's morale. He neither treated her nor was he a member of the team of
doctors treating Anuradha at AMRI. As despite requests he had not participated
in the treatment of the deceased, Kunal implicated him falsely.
Respondent No. 4 contended that the Appellant was fully aware of the absence of
a burn ward in AMRI at the time of admission of the deceased patient.
Furthermore, the deceased was shifted to a VIP cabin in the hospital which was
fully isolated, with environmental temperature control. Moreover it was Kunal,
himself who had prevented the nursing staff from taking the temperature, blood
pressure etc. Also the infection, as alleged, aggravated due to transportation
of the deceased from Kolkata to Mumbai. Moreover non administration of IV
fluids is a matter of judgment for the treating doctor and is not open to the
Hospital Management to interfere with.
Respondents 5, Dr. Balaram Prasad contended that the medical treatment sheet of
AMRI dated 11.5.1998, would show that he not only attended the patient for the
first time but he also meticulously noted the diagnosis and continued the same
medicine for one day as 17 was prescribed by Dr. Mukherjee. Before, however, medicines
as per his prescription could be administered, Respondent Nos.1 and Respondent
2 took over the treatment.
Respondent 6, denied the allegation of the appellant that he did not give
effect to the medical protocol while dressing Anuradha.
to him, reference was made to him by Respondent No.5 for the sole purpose of
dressing the patient. He took care of the patient as far as wound care was
concerned and did the dressing as per medical norms in support whereof reliance
was placed on the opinion of Dr. Jean Claude Roujeau of France.
did not plead guilty, they were put to trial in the criminal matter.
the learned Chief Judicial Magistrate, South - 24 Parganas, Alipore, the
prosecution examined 11 witnesses. The complainant Malay Kumar Ganguly examined
himself as PW-1 whereas husband of the deceased Kunal examined himself as PW-2.
Dr. Balaram Prasad who was a visiting consultant of AMRI at the relevant time
was examined as PW-3. He is Respondent No 5 in the connected civil appeal. Dr.
Aloke Majumdar attached to the B.R. Singh Railway Hospital, Sealdah as Senior
Divisional 18 Medical officer (ENT) examined himself as PW-4. PW-5 is Dr. Anil
Kumar Gupta who was attached to the Sub-divisional Hospital, Asansol as a
Medical Officer. The President of the West Bengal Medical Council Dr.
Kumar Chowdhury was examined as PW-6. Prasenjit Bhattacharjee, a Sub-Inspector
of Kolkata Police who was attached to the Lake Police Station at the relevant
time was examined as PW-7. Dr. Anil Shinde, a medical practitioner and Manager
of Pharmacia India Limited, Gurgaon, Haryana (the company manufacturing
Depomedrol) was examined as PW-8. Dilip Kumar Ghosh who was the Registrar, West
Bengal Medical Council has been examined as PW-9. Dr. Faruk E. Udwadia, a
consultant physician with specialization in critical care and respiratory
medicine of Breach Candy Hospital, Mumbai who treated the deceased from 12th
May, 1998 to 18th May, 1998 was examined as PW-10. Dr. Salil Kumar
Bhattacharjee, Professor of Pharmacology Institute of Medical Science, Benaras
Hindu University was examined as an expert witness PW-11 on behalf of the
defence has also examined 3 witnesses. DW-1 Smt. Sutapa Chanda is the Nursing
Superintendent of A.M.R.I. Dr. Kaushik Nandy, a Plastic Surgeon attached to
AMRI, who is a Respondent in the connected Civil Appeal and had treated the
deceased, was examined as DW-2. Mihir 19 Pal, a Group `D' staff attached to
Asansol Sub-Sivisional Hospital was examined as DW-3.
prosecution proved as many as 20 documents, whereas the defence has proved 4
the learned Trial Judge as also before the Commission, the parties hereto had
relied upon several medical text books of different authors, journals, research
papers/ deliberations of the National Conference on Medical Science,
transcripts of CDs, package insert, etc. One audio cassette has been produced
on behalf of the complainant to prove the conversation which took place between
him and the President of the West Bengal Medical Council Dr. Ashoke Kumar
Court observed as under:
cause of death of Anuradha was Septicemia shock with multi- organ failure
leading to cardio-respiratory arrest.
Breach Candy Hospital, Mumbai was not responsible for causing the death of
III. Re :
Dr. Sukumar Mukherjee:
20 (i) He
having been consulted by Dr. Kunal Saha since the 4th week of April, 1998,
i.e., at his residence, at his chamber at Nightingale Diagnostic & Eye Care
Rresearch Centre Private Limited and particularly on 3rd May, 1998, 4th May,
1998, 7th May, 1998 as also on 11th May, 1998 at AMRI and his line of treatment
having been followed despite his leaving abroad on the night of 11th May, 1998,
his defence that his prescription from the afternoon of 11th May, 1998 became
automatically redundant and inoperative cannot be accepted from a doctor of his
status. Such a stand taken by him was not only a motivated one but beyond the
moral obligation of a doctor to his patients. The medicine was prescribed by
him [ Corticosteriod, viz., Depomedrol (Methyleprednisolone Acetate) ] without
even diagnosing a disease. But, he did not advise symptomatic therapy like bed
rest, elevation of the legs and bandage to reduce Oedema nor prescribed any
medicine for control of the underlying disease. It was held:
vessel vasculitis are of different kinds of which allergic vasculitis is one.
It corresponds approximately to Hypersensitivity Angilis. The term allergic is
little contentious since it implies a immunological etiology which may be an
over simplification. Allergic vasculitis is the 21 most common part of
Leucocytoclastic vasculitis in adults. It is characterized by purpuric or
necrotic skin lesions, with or without systemic features. Rheumatoid Arthritis
is the most common association with coetaneous leucocytoclastic
least on 11th May, 1998, Anuradha was correctly diagnosed by Dr. A.K. Ghoshal
as also the following day by Dr. B.N. Halder, still application of
Corticosteriod Prednisolone for all these days in prohibitive quantity and
dosing intervals with no supportive therapy was continued. That made her lose
all her immunity to fight out bacteria and become immunosuppressed leading to
`Septicemia' or `Septic shock'.
5 and 11 also deposed about high dose of Depomedrol. Its adverse effects caused
`Immunosuppression' and `Septicemia' which resulted in the death of Anuradha.
working Manager of Pharmacia India Ltd., Dr. Anil Shinde (PW-8) has categorically
stated that the maximum recommended dose of Depomedrol for any dermatological
or other clinical condition is 40 mg to 120 mg once a week or once in two weeks
as 22 per the severity of the disease and clinical need. Depomedrol cannot be
given 80 mg twice daily in any clinical condition and even in the right dose it
is not recommended for TEN patients as it is a long acting steroid. Therefore,
musking of infection, latent infections become active and opportunistic
infections are likely as it has immunosuppressive action. The package insert of
Depomedrol in U.S.A. indicates that Corticosteroids may musk some signs of
infections and new infections may appear during their use.
Another expert Dr. Salil Kumar Bhattacharya (PW-11) has gone further and stated
that Depomedrol has a prolonged duration of action. The half life of the drug
is 139 hours for which 80 mg twice daily is excessive which is dangerous for
the patient and the immediate adverse effect of overuse of this steroid is
immunosuppression and chance of opportunistic infection. Sepsis is a severe
infective condition which is systemic in nature and is caused by rapid growth
and multiplication of infective organism as opined by PW-11.
Anil Kumar Gupta (PW-5) made correspondences with Pharmacia Upjohn to receive
the following reply:
"...our package insert on Depomedrol does not recommend the twice daily
dose of injection Depomedrol 80 mg. in any clinical condition..."
his opinion, the use of Depomedrol in high doses can cause immunosuppression
and H.P.A. Axis suppression as per package insert.
Dr. Balaram Prasad who admittedly treated Anuradha had doubt with regard to the
treatment of the patient and sought immediate advice regarding continuation of
the drug from Dr. Mukherjee and others. However, he was asked to continue with
the medicine by Dr. Mukherjee which was started by Dr. Roychowdhury, the
Mukherjee did not follow the treatment guidelines provided for in the Journals.
The resolution taken in an International Conference known as Creteilis
Experience, 1987 authored by J.
J.C. Roujeau (Ref. Archives of Dermatology, Vol.
pages 1156-57) had also not been followed.
Although steroids are used but the supposed advantage of the said therapy are
far outweighed by its drawbacks. It is not used as a standard therapy in TEN.
Although use of Corticosteroid is advocated in the treatment of TEN, reports
from early 1980s condemn their use.
husband of the deceased is a Non-Resident Indian settled in America as a
doctor. The complainant examined doctors from different corners of the country.
On the other hand, the witnesses examined on behalf of the defence were one
doctor, one Nursing Superintendent and one employee of the Department of
Health, Govt. of West Bengal.
is not denied by Dr. Mukherjee in his examination under Section 313 of the Code
of Criminal Procedure that immunosuppression, infection and sepsis are the
serious adverse effects of Corticosteroids as also the probable effect of the
overuse and excessive dose of the said steroids including Depomedrol.
Even Dr. Kaushik Nandy (DW-2) admitted that immunosuppression can be a
side-effect of overuse or excessive 25 use of Corticosteriods and may cause a
chance of infection in any patient. He admitted that steroids should not be
used as a standard therapy for treatment of TEN.
Fitz Patrick's Dermatology for General Medicine, the text book on which both
sides placed reliance, it is stated that "Glucocorticosteroids (steroids)
may promote the risk of infection (Pneumonia, Septicemia)".
Steroid was used in the Breach Candy Hospital, as deposed by PW-10, to
completely taper the dose as the patient had very high-circulating steroid
level in her body because of her receiving 120 mg. of Prednisolone daily in
Kolkata and it was done for her safety only. The point with regard to
Haemodialysis was not put to Dr. Udwadia and, thus, no benefit in this behalf
can be given to defence.
Kaushik Nandy (DW-2) has admitted that a very high circulating steroid level in
a patient may appear if large doses of steroids are administered.
(viii)Non-examination of some witnesses like the brother of the deceased
Amritava Roy and sisters of AMRI was not very material.
Sukumar Mukherjee was accordingly held guilty of the charge of negligence.
Baidyanath Halder (i) He although diagnosed correctly but prescribed steroids.
according to him, he had examined Anuradha only once and no feedback about her
condition was given to him. If he was so sincere and careful, he could have
collected the information about the condition of the patient with regard to the
result of his treatment from the Hospital authorities or the patient party. He
had issued a certificate on 16th May, 1998. His prescription of Prednisolone 40
mg. thrice daily and Minabol twice daily was followed by the nurses of AMRI, as
stated by Sutapa Chanda (DW-1).
Halder was intimated about the prescription of Dr. Mukherjee and the fact that
Anuradha had already received 800 mg. of Depomedrol which is equivalent to 1100
mg. of Prednisolone but 27 despite the same he had advised Prednisolone three
times a day without any supportive therapy which is mandatory for the patient
of TEN as accepted by different universal protocols.
Dr. Halder advised against pricking of needles in case of such patients, no
supportive treatment could be administered.
view of the certificate given by Dr. Halder, the court had reason to believe
that he treated the patient from 12th May, 1998 at least upto 16th May, 1998.
Non-tapering of doses of steroid is in violation of the treatment protocol for
the disease TEN. The principles of supportive care have been violated totally
in the prescription of Dr. Halder.
his statement under Section 313 of the Code of Criminal Procedure, he had taken
a specific plea that "journey from Kolkata to Bombay likely to enhance the
danger", still, he had issued the certificate.
purported interpolation of three words "for better treatment" did not
make any difference, i.e., in the certificate itself to show that it was issued
at the instance of the patient party.
(viii)The defence that the patient was removed at their own risk is not correct
as Dr. Saha did not furnish any risk bond and only some other person not
connected with the patient had endorsed the record for taking the patient at
his own risk. In any event, such undertaking was not of much significance.
accused doctor should not be allowed to raise the question of chance of
infection in transit from Kolkata to Mumbai as Anuradha was suffering from TEN
which is a non-infectious disorder and she was found fit to travel from Kolkata
to Mumbai. In view of her physical condition which was found at Breach Candy
Hospital, the certificate issued does not properly reflect the actual physical
condition of the patient, which itself amount to avoidance of responsibility on
the part of the treating Physician.
Abani Roychowdhury (i) There is nothing to show that Dr. Roychowdhury treated
Anuradha except the entries which appeared in the prescription of Dr. Mukherjee
dated 11th May, 1998, viz., "May I request Dr. Abani Roychowdhury to see
her" and another endorsement dated 15th May, 1998 wherein PW-3 Dr. B.
Prasad wrote to continue as 29 advised by Dr. Mukherjee and Dr. Abani
Roychowdhury. There is nothing to show that he issued any prescription.
statement of DW-1 that Dr. Roychowdhury had been to AMRI is wholly unworthy of
credence as she is a hearsay witness having heard the same from PW-2 who in his
evidence did not state thereabout.
statement made by DW-2 in his affidavit affirmed in the case before the
Commission stating that "I carried out and suggested necessary treatment
in conformity with the general treatment pattern prescribed by senior
consultants, namely O.P. Nos. 2 and 3 who were generally heading the medical
team looking after the treatment of the deceased. All the steps were taken to
minimize chance of infection and discomfort to the patient/deceased" has
not been proved as only a Xerox copy of the same had been produced.
complainant has failed to establish the role of Dr. Roychowdhury in the
treatment of Anuradha.
defence story that Dr. Saha had interfered in the matter of treatment, as
deposed by DW-2 is not borne out from the treatment sheet and consultation
record maintained and kept by the nurses at 30 AMRI particularly in view of the
statement of DW-1 that Anuradha's nurses had been maintaining all the records.
There is nothing on record to show that any advice was given for biopsy. It was
not necessary to conduct the post-mortem on the dead body of Anuradha as the
cause of death, as expressed by Dr. Udwadia, was known. Immunosuppression
having been found by Dr. Udwadia, permission for laboratory tests was not
High Court on the other hand in its judgment observed that in view of the
nature of the offence under Section 304-A, coupled with the fact that the
penalty imposed therefor was imprisonment for two years, the Chief Judicial
Magistrate should have converted the summons case into a warrant one.
C.J.M. should not have issued warrant of arrest without treating the case into
a warrant case.
should have been considered that three renowned professors of the State could
have been man handled (by the police) on the basis of said arrest warrant.
The fact that accused doctors did not levy any professional fees was also a
matter of relevance.
absence of the post-mortem examination with regard to the cause of death of
Anuradha, it must be held that the death was a natural one.
certificate issued by the Breach Candy Hospital, Mumbai was not a conclusive
proof of the cause of death but was only a tentative one. It was silent about
the antecedent cause or other significant conditions contributing to the death.
The death certificate could not rule out the possibility of accidental, suicidal
or homicidal cause of death. The doctor who issued the death certificate was
not examined. Thus immediate cause of death vis-a-vis the link thereof with the
treatment at Kolkata and that too specially at the hands of Respondents 1 to 3
was not proved.
Improvement to her health noticed in the Mumbai hospital after 25th May, 1998
ran contrary to the contention of complainant.
Re : DR.
MUKHERJEE The allegation that he was responsible for causing the death of
Anuradha by his rash and negligent act not amounting to culpable homicide by
advising, prescribing and treating the deceased with steroid drugs namely 32
Depomedrol, 80 mg, IM stat twice daily and other drugs in improper dosage at
improper interval without any supportive treatment was rejected for the
following reasons :- (i) Various tests advised by him were not undertaken and
he was not apprised of the treatment chart of Anuradha for the period 3rd
April, 1998 to 6th May, 1998.
Anuradha admittedly was suffering from certain allergic disorders which were
aggravated due to the intake of Chinese food and for treating such allergic
disorders generally steroids would be used and thus the trial court was not
correct to hold that Dr. Mukherjee should not have prescribed Depomedrol.
There is nothing on record to show that the drug was actually administered to
the patient because no feedback of the treatment was given to him.
the time of admission at AMRI, Dr. Mukherjee's prescription was not taken into
consideration. In fact it was indicated that the patient was being treated by
somebody else whose identity had not been disclosed.
Diagnosis that Anuradha was suffering from TEN was not done by Dr. Mukherjee.
The package insert of Depomedrol did not indicate that it could not be prescribed
for the said disease. As Anuradha is stated to be suffering from vasculitis and
could be treated with the said medicine, which opinion has been supported by
others including Dermatologist - Dr. A.K. Ghoshal, it could not be construed to
be incorrect and contrary to medical practice and ethos.
Ghosal was not examined to explain the basis upon which the patient was
diagnosed to be suffering from TEN.
Oral admission of Tab. Wysolone was sufficient to indicate that the treatment
of the patient was being carried out as per the prescription of Dr. Mukherjee.
However, in any event the evidence on record was sufficient to indicate that
from 3rd April, 1998 till her admission at AMRI on 11th May, 1998, Anuradha was
being treated after taking advice from different doctors.
evidence on record to indicate that Kunal's doctor friends contributed in her
There is a possibility of Anuradha suffering from drug allergy as well as
allergy from Chinese foods. Application of steroid is undoubtedly an accepted
treatment protocol for allergic disorders. In fact, Depo-Medrol is a
Glucocorticoid which has anti inflammatory and anti-allergic action.
Allergic vasculitis is an allergic and inflammatory condition of the blood
vessels in the body and can affect not only the blood vessels of the skin but
also any internal vital organs leading to death of the patient at any point of
time. Allergic vasculitis is not a dermatological disease. The treatment
suggested by Dr. Mukherjee, therefore, could not be considered to be an act of
rash and negligence.
Re : DR.
HALDER The allegation of the complainant that the prescription by Dr. Halder of
Prednisolone 40 mg. thrice daily had aggravated the disease was held not
tenable on the following grounds :- (i) He visited the patient only on 12th
May, 1998 which was supported by Dr. Balaram Prasad. He, therefore, had no role
to 35 play in the treatment of Anuradha which would be evident from the record
There is nothing on record to show that the prescription of Prof. Halder was
given effect to.
Occlusive dressings were carried as a result of which infection had been
increased (iv) He had suggested Benadryl Syrup as there were eruptions inside
the mouth and Cortisone Kemicetin eye ointment for eye care. However, the
steroid based Neomycin Antibiotic was prescribed by the Consultant
Ophthalmologist Dr. S. Bhattacharya on 12th May, 1998, although Prof. Halder in
his prescription advised to avoid Neomycin and Soframycin which are common
causes of drug allergy. As such the treatment suggested by Prof. Halder was not
was no evidence to show that he was incharge of the patient.
There was no evidence to indicate that Dr. Mukherjee ever requested Dr. Halder
to see the patient.
Despite the fact that Dr. Halder confirmed that the patient was suffering from
TEN, records indicated that his line of treatment was not followed and, thus,
the evidence to consider the deceased to be suffering from TEN is of no value.
Anuradha was thus not suffering from TEN. Although the papers of Breach Candy
Hospital mention that the disease was diagnosed as TEN, but the attending
physician was not a dermatologist. Thus no one came forward to say that Anuradha
was suffering from TEN.
death certificate also did not indicate that Anuradha was suffering from TEN.
Kunal Saha, husband of the deceased Anuradha being himself not a Dermatologist;
his opinion is irrelevant, particularly when he is said to have become
specialist of TEN subsequently upon studying the subject after her death.
Prescription of Prof. Halder indicated that he stopped Depo- Medrol once he
started Prednisolone 40 mg. thrice with other medicines. He also prohibited
local anesthesia, Neomycin, 37 Soframycin. He also gave importance on
Elecrtolyte balance, nutrition and advised for prevention of secondary
Prof. Halder is a renowned Dermatologist with numerous publications and
teaching experience. His line of treatment was in conformity with the accepted
norms particularly in view of the fact that there is no universal protocol for
the treatment of TEN. Treatment of each patient will depend upon his/her
condition on a particular day.
During Anuradha's stay at AMRI there was no indication of any complication like
hypovolemia, internal organ failure, infection of septicemia etc.
PROF. ABANI ROY CHOWDHURY.
that he had also taken active part in the treatment of Anuradha is not
established from the record.
nothing on record to show that Dr. Halder while writing the prescription had
any prior discussion with Dr. Abani Roychowdhury. The 38 endorsement that the
prescription was a joint prescription of Dr. Halder and Dr. Roychowdhury was
admittedly made by Dr. Kunal Saha himself Although some of the doctors of AMRI
had stated that they had received the advice of Dr. Roychowdhury but the nature
of the advice had not been clarified by them.
CERTIFICATE The allegation that the certificate was issued at the instance of
is not correct as the certificate issued by Prof. Halder did not indicate that
Anuradha was being carried by a Chartered flight for better treatment. The
words "for better treatment" were not written by Prof.
and only in the course of evidence it was proved that there was an
interpolation in the certificate. The same was also admitted by Dr. Balaram
Prasad and thus the certificate of Prof. Halder was held to be forged. The
forged certificate demolishes the prosecution story that at the advice of Prof.
Prof. Roychowdhury the patient was taken to Mumbai. The endorsement of Dr.
Kunal Saha on the record of AMRI really proved that Anuradha was shifted from
the hospital at their own risk. The evidence on record also indicates that till
the evening of 18th May, 1998, the dressing of Anuradha was not changed. Thus,
by removing Anuradha, her husband 39 Kunal Saha took upon himself great risk of
infection to her in course of transit being aware that infection was very
common at that critical stage for the patient.
doctors had no hand in shifting Anuradha from Kolkata to Mumbai.
Court also opined that the patient party did neither follow the advice of Dr.
Mukherjee nor that of Prof. Halder.
OBSERVATIONS BY THE HIGH COURT (i) As Anuradha was treated at AMRI for six days
and at Breach Candy Hospital for 12 days, by no stretch of imagination her
death had anything to do with the treatment at AMRI ; the cause of death being
contention of Dr. Kunal Saha that his wife was almost dead when brought to
Breach Candy Hospital, was untrue.
Anuradha was admitted under Dr. Balaram Prasad, who was a Consultant Physician
having Post Graduate Degree. He also claimed to be the physician-in-charge of
Interference by Dr. Kunal Saha was sufficient to indicate that treatment of
Anuradha was monitored by him alone and nobody else.
Although, he claimed that Anuradha was suffering from TEN which was a
dermatological disease, but Anuradha was admitted by him under a Plastic
Surgeon, Dr. S. Keshwani. Even at the initial stage Dr. Kunal Saha gave
instructions to the doctors on 17th May, 1998 rejecting the treatment suggested
by doctors attending at Breach Candy Hospital, Mumbai. Thus the diagnosis of
the disease and the follow-up action was done under the direct supervision of
Dr. Kunal Saha and his brother-in-law. Such was the position at AMRI also.
opinion of three internationally-accepted experts on TEN was not acceptable as
none of them were examined in Court. From the records of Breach Candy Hospital
it would itself appear that Anuradha was being administered medicines other
than the ones prescribed by the doctors. Cash memos for purchase of medicines
would show the discrepancy in the medicines prescribed by the doctors like
Bactroban Ointment, Efcorlin (one kind of steroid) and Sofratule purchased on
12th, 13th and 16th May, 1998 had not been prescribed by the doctors. Relatives
of the patient having not followed the treatment protocol of the doctors under
whom the patent is admitted; as soon as any interference is made therewith, the
doctors are absolved of their liability.
of professional negligence on a medical person is a serious one as it affects
his professional status and reputation and as such the burden of proof would be
more onerous. A doctor cannot be held negligent only because something has gone
wrong. He also cannot be held liable for mischance or misadventure or for an
error of judgment in making a choice when two options are available. The
mistake in diagnosis is not necessarily a negligent diagnosis.
under the law of tort a medical practitioner can only be held liable in respect
of an erroneous diagnosis if his error is so palpably wrong as to prove by
itself that it was negligently arrived at or it was the product of absence of
reasonable skill and care on his part regard being held to the ordinary level
of skill in the profession. For fastening criminal liability very high degree
of such negligence is required to be proved.
the ultimate result of all serious ailments and the doctors are there to save
the victims from such ailments. Experience and expertise of a doctor are
utilised for the recovery. But it is not expected that in case of all ailments
the doctor can give guarantee of cure.
Commission in its judgment noted that doctor or a surgeon never undertakes that
he would positively cure the patient nor does he undertake to use the highest
degree of skill, but he only promises to use fair, reasonable and competent
degree of skill. In this regard the commission opined that if there are several
modes of treatment and a doctor adopts one of them and conducts the same with
due care and caution, then no negligence can be attributed towards him It went
on to note that there was no negligence on part of Dr. Mukherjee because even
Dr. A. K. Ghoshal, Dermatologist, who diagnosed the disease of Mrs. Anuradha as
TEN, prescribed the same treatment.
it observed that no records were produced by Dr. Saha regarding the treatment
given to Mrs. Anuradha from 1st April 1998 to 7th May 1998. As there is no
specific treatment for TEN, error of judgment in the process of diagnosis does
not amount to deficiency in service, considering that the disease TEN is a rare
occurring in 1 case out of 1.3 per million per year.
on to observe that the patient was never in the absolute care of Dr. Haldar,
who had treated her only on 12th of May 1998. Dr. Haldar, it noted, was,
therefore, an unnecessary party.
opined that all the necessary care was taken by Dr. Mukherjee and Dr. Haldar.
It laid special emphasis on the fact that a complaint had been filed before the
West Bengal Medical Council, which concluded that there was no deficiency on
the part of the doctors. The Writ petition against the said decision before the
High Court was dismissed. Therefore, it was concluded that there was no
negligence on the part of the doctors.
DETERMINATION OF CERTAIN SALIENT POINTS OF LAW AND FACTS
EXPERT EVIDENCE Section 45 of the Indian Evidence Act speaks of expert
evidence. It reads as under :- "45. Opinions of experts - When the Court
has to form an opinion upon a point of foreign law, or of science, or art, or
as to identity of hand writing or finger-impressions, the opinions upon that
point of persons specially skilled in such foreign law, science or art, or in
questions as to identity of handwriting or finger impressions, are relevant
facts. Such person called experts.
(a) The question is, whether the death of A was caused by poison. The opinions
of experts as to the symptoms produced by the poison by which A is supposed to
have died, are relevant.
The question is whether A, at the time of doing a certain act, was by reason of
unsoundness of mind, in capable of knowing the nature of the act, or that he
was doing what was either wrong or contrary to law.
opinions of experts upon the question whether the symptoms exhibited by A commonly
show unsoundness of mind, and whether such unsoundness of mind usually renders
persons incapable of knowing the nature of the acts which they do, or knowing
that what they do is either wrong or contrary to law, are relevant.
question is, whether a certain document was written by A. Another document is
produced which is proved or admitted to have been written by A.
opinion of experts on the question whether the two documents were written by
the same person or by different persons are relevant."
is not bound by the evidence of the experts which is to a large extent advisory
in nature. The Court must derive its own conclusion upon considering the
opinion of the experts which may be adduced by both sides, cautiously, and upon
taking into consideration the authorities on the point on which he deposes.
science is a difficult one. The court for the purpose of arriving at a decision
on the basis of the opinions of experts must take into 45 consideration the
difference between an `expert witness' and an `ordinary witness'. The opinion
must be based on a person having special skill or knowledge in medical science.
It could be admitted or denied. Whether such an evidence could be admitted or
how much weight should be given thereto, lies within the domain of the court.
The evidence of an expert should, however, be interpreted like any other
Court in State of H.P. v. Jai Lal and others, [ (1999) 7 SCC 280] held as under
:- " 17. Section 45 of the Evidence Act which makes opinion of experts
admissible lays down that when the court has to form an opinion upon a point of
foreign law, or of science, or art, or as to identity of handwriting or finger
impressions, the opinions upon that point of persons specially skilled in such foreign
law, science or art, or in questions as to identity of handwriting, or finger
impressions are relevant facts. Therefore, in order to bring the evidence of a
witness as that of an expert it has to be shown that he has made a special
study of the subject or acquired a special experience therein or in other words
that he is skilled and has adequate knowledge of the subject.
expert is not a witness of fact. His evidence is really of an advisory
character. The duty of an expert witness is to furnish the Judge with the
necessary scientific criteria for testing the accuracy of the conclusions so as
to enable the Judge to form his independent judgment by the application of this
criteria to the facts proved by 46 the evidence of the case. The scientific
opinion evidence, if intelligible, convincing and tested becomes a factor and
often an important factor for consideration along with the other evidence of
the case. The credibility of such a witness depends on the reasons stated in
support of his conclusions and the data and material furnished which form the
basis of his conclusions.
report submitted by an expert does not go in evidence automatically. He is to
be examined as a witness in court and has to face cross- examination. This
Court in the case of Hazi Mohammad Ekramul Haq v. State of W.B. concurred with
the finding of the High Court in not placing any reliance upon the evidence of
an expert witness on the ground that his evidence was merely an opinion
unsupported by any reasons."
OF EXHIBITS 4, 5 AND 6 Kunal, before us, contended that the High Court
committed a serious error in not placing reliance upon medical opinions i.e.
Exts. 4, 5 and 6 on the premise that no objection in that behalf was raised at
any point of time.
would argue that this Court having given him permission to examine the expert
witnesses on Video Conferencing and he having deposed in terms thereof,
Respondents could have asked for their cross-examination at any point of time
and not having done so, it does not lie in their mouth to 47 contend that the
opinions of the said experts who are themselves authors on TEN and having done
research on the disease TEN, are not admissible.
PURPOSES OF CRIMINAL PROCEEDINGS Kunal, however, would contend that the
aforementioned documents were exhibited without any demur whatsoever. The
respondents, furthermore, did not make any prayer to cross-examine the said
true that ordinarily if a party to an action does not object to a document
being taken on record and the same is marked as an exhibit, he is estopped and
precluded from questioning the admissibility thereof at a later stage. It is,
however, trite that a document becomes inadmissible in evidence unless author
thereof is examined; the contents thereof cannot be held to have been proved
unless he is examined and subjected to cross- examination in a court of law.
document which is otherwise inadmissible cannot be taken in evidence only
because no objection to the admissibility thereof was taken.
criminal case, subject of course, to the shifting of burden depending upon the
statutes and/or the decisions of the superiors courts, the right of an accused
is protected in terms of Article 21 of the Constitution of India. The 48
procedure laid in that behalf, therefore, must be strictly complied with.
4, 5 and 6, in our opinion, are not admissible in evidence in the criminal
PURPOSES OF PROCEEDINGS BEFORE THE NATIONAL COMMISSION The said exhibits,
however, are admissible before the consumer court.
Court in R.V.E. Venkatachala Gounder v. Arulmigu Viswesaraswami & V.P.
Temple,(2003) 8 SCC 752, at page 763 :
Ordinarily, an objection to the admissibility of evidence should be taken when
it is tendered and not subsequently. The objections as to admissibility of
documents in evidence may be classified into two classes: (i) an objection that
the document which is sought to be proved is itself inadmissible in evidence;
and (ii) where the objection does not dispute the admissibility of the document
in evidence but is directed towards the mode of proof alleging the same to be
irregular or insufficient. In the first case, merely because a document has
been marked as "an exhibit", an objection as to its admissibility is
not excluded and is available to be raised even at a later stage or even in
appeal or revision. In the latter case, the objection should be taken when the
evidence is tendered and once the document has been admitted in evidence and
marked as an exhibit, the objection that it should not have been admitted in
evidence or that the mode adopted for proving the document is irregular cannot
be allowed to be raised at any stage subsequent to the marking of the document
as an 49 exhibit. The latter proposition is a rule of fair play.
crucial test is whether an objection, if taken at the appropriate point of
time, would have enabled the party tendering the evidence to cure the defect
and resort to such mode of proof as would be regular. The omission to object becomes
fatal because by his failure the party entitled to object allows the party
tendering the evidence to act on an assumption that the opposite party is not
serious about the mode of proof. On the other hand, a prompt objection does not
prejudice the party tendering the evidence, for two reasons: firstly, it
enables the court to apply its mind and pronounce its decision on the question
of admissibility then and there; and secondly, in the event of finding of the
court on the mode of proof sought to be adopted going against the party
tendering the evidence, the opportunity of seeking indulgence of the court for
permitting a regular mode or method of proof and thereby removing the objection
raised by the opposite party, is available to the party leading the evidence.
Such practice and procedure is fair to both the parties. Out of the two types
of objections, referred to hereinabove, in the latter case, failure to raise a
prompt and timely objection amounts to waiver of the necessity for insisting on
formal proof of a document, the document itself which is sought to be proved
being admissible in evidence. In the first case, acquiescence would be no bar
to raising the objection in a superior court."
22 of the Consumer
Protection Act, 1986 provides that Sections 12, 13
and 14 thereof and the rules made there under for disposal of the complaints by
the District Forum, shall with such modification as may be considered necessary
by the Commission, be applicable to the disposal of disputes by the National Commission.
Section 12 of the 1986 Act provides 50 for the manner in which the complaint
shall be made. Section 13 prescribes the procedure on admission of the
complaint. Sub-section (3) thereof reads:- "(3) No proceedings complying
with the procedure laid down in sub-sections (1) and (2) shall be called in
question in any court on the ground that the principles of natural justice have
not been complied with."
from the procedures laid down in Section 12 and 13 as also the Rules made under
the Act, the Commission is not bound by any other prescribed procedure. The
provisions of the Indian Evidence Act are not applicable. The Commission is
merely to comply with the principles of natural justice, save and except the
ones laid down under sub-section (4) of Section 13 of the 1986 Act.
proceedings before the National Commission are although judicial proceedings,
but at the same time it is not a civil court within the meaning of the
provisions of the Code of Civil Procedure. It may have all the trappings of the
Civil Court but yet it cannot be called a civil court.
Bharat Bank Ltd. v. Employees of the Bharat Bank Ltd. [1950 SCR 459] and Nahar
Industries Ltd. v. Hong Kong & Shanghai Banking Corporation etc. (Civil
Appeal arising out of SLP (C) No. 24715 of 2008 etc decided on 29th July,
2009)] 51 Mr. Gupta, learned counsel appearing on behalf of Dr. Balram Prasad
contended that the opinions, exhibits P-4, P-5 and P-6 are inadmissible in
opinions of the experts as contained in the said documents are probably based
on the hospital records and other relevant papers. Such opinions have been
rendered on the basis of their expertise. They were notarized. The said
opinions have been appended to the complaint petition even as documents.
Respondents did not question the correctness thereof either before the court or
before the Commission. They did not examine any expert to show that said
opinion are not correct. The concerned respondents in their depositions before
the Commission also did not challenge the correctness or otherwise of the said
opinions. Even otherwise the deficiencies pointed out therein are explicit from
Court in J.J. Merchant (Dr) v. Shrinath Chaturvedi, [(2002) 6 SCC 635], held as
under :- "19. It is true that it is the discretion of the Commission to
examine the experts if required in an appropriate matter. It is equally true
that in cases where it is deemed fit to examine experts, recording of evidence
before a Commission may consume time. The Act specifically empowers the
Consumer Forums to follow the procedure which may not require more time or
delay the proceedings. The 52 only caution required is to follow the said
procedure strictly. Under the Act, while trying a complaint, evidence could be
taken on affidavits [under Section 13(4)(iii)]. It also empowers such Forums to
issue any commission for examination of any witness [under Section 13(4)(v)].
It is also to be stated that Rule 4 in Order 18 CPC is substituted which inter
alia provides that in every case, the examination-in-chief of a witness shall
be on affidavit and copies thereof shall be supplied to the opposite party by
the party who calls him for evidence. It also provides that witnesses could be
examined by the court or the Commissioner appointed by it. As stated above, the
Commission is also empowered to follow the said procedure.
do not think that there is any scope of delay in examination or
cross-examination of the witnesses. The affidavits of the experts including the
doctors can be taken as evidence. Thereafter, if cross-examination is sought
for by the other side and the Commission finds it proper, it can easily evolve
a procedure permitting the party who intends to cross-examine by putting
certain questions in writing and those questions also could be replied by such
experts including doctors on affidavits. In case where stakes are very high and
still a party intends to cross-examine such doctors or experts, there can be
video conferences or asking questions by arranging telephonic conference and at
the initial stage this cost should be borne by the person who claims such video
conference. Further, cross-examination can be taken by the Commissioner
appointed by it at the working place of such experts at a fixed time."
DIAGNOSIS AND TRAIL OF TREATMENT OVERVIEW OF TOXIC EPIDERMAL NNECROLYSIS 53
Toxic Epidermal Nnecrolysis (TEN hereinafter) is also known as Lyell's
Syndrome, epidermolysis acuta toxica and scalded skin syndrome.
begins with a non- specific prodome of 1- 14 days in at least half of the
patients. It is a severe and extensive variant of erythematobullous drug
eruption. In TEN, the patient is ill with high fever occasionally suffers
somnolence and lassitude. Because of the extensive area of eroded skin, large
amount of body fluid is lost with consequent disturbances of electrolyte and
fluid balance. [See Dermatology in General Medicine ( Fitz Patrick's) (5th Ed),
and Comprehensive Dermatological Drug Therapy] NEGLIGENCE IN TREATMENT OF TEN
For determining the question as to whether the respondents herein are guilty of
any negligence, we may notice the treatment protocol.
it is conceded, was suffering from TEN. She had been positively diagnosed to be
suffering from the said disease on 12th May, 1998.
TEN is a spectrum
of symptoms. The treatment protocol for TEN has undergone considerable change
throughout the world.
discovered in the year 1956 by Lyell. It leads to immune suppression. For
treating the patients suffering from TEN, doctors used to administer steroid.
Later researches showed that they should not be 54 used. Such a conclusion was
arrived at upon undertaking researches of patients suffering from the said
disease with administration of steroid as well as non-administration of them.
It was found that those patients treated with steroids do not respond properly
thereto. Indisputably, however, some doctors still use steroids. It is stated
that the researchers found out that use of steroids was more detrimental than
beneficial to the TEN patients.
Anuradha was administered steroids. The learned counsel for the parties have
brought before us a vast volume of material to contend that the experts in the
field as also the doctors or medical practitioners who have specialized in TEN
and other dermatological diseases are sharply divided on the administration of
steroid. We for the sake of brevity refer to them as the pro-steroid group and
science, therefore, has a grey area in this respect.
outset, we may place on record the treatment pattern prescribed by two experts,
viz., Jean Edouard Revuz and Jean Claude Roujeau who are generally accepted
world over. According to them, the treatment pattern should be as under:
disease usually begins with non specific symptoms, such as fever, cough, sore
throat, burning eyes, followed in 1 to 3 days by skin and mucous membrane
lesions. A burning or painful 55 rash starts systematically on the face and in
the upper part of the tongue and rapidly extends. Most frequently, the initial
individual skin lesions form poorly defined margins with darker purpuric centre
progressively emerging on the skin, chest and back. Less frequently, the
initial manifestations may be extensive scarlatiniform erythema.
therapy is a must. IV fluids must be replaced mandatorily.
treatment protocol includes:
Symptomatic treatment 7 Monitoring 7 Fluid replacement and anti-infection
therapy 7 Nutrition 7 Warming (30-32 degree Celsius) 7 Skin care 7 Eyes and
mucous membrane care"
the view that the current evidence suggests that corticosteroids are more
dangerous than useful in these disorders as they increase the risk of death
from infections, including systemic candidiasis, a complication that had never
been observed in many patients treated without steroids.
death of Anuradha, Kunal consulted a large number of experts from various
countries including India.
Canadian Treatment Protocol is as under:
"IV fluid resuscitation- including internal feeding, use of air- fluidized
beds, complete avoidance of steroids, use of narcotics for pain, use of
catheters to be avoided, meticulous eye care daily, use of systemic antibiotic
therapy for specific infections but not for prophylaxis, topical antibiotic therapy
is not used, meticulous wound care and moist saline gauge dressing are applied
once daily when most of the involved epidermal surface has sloughed off,
usually 3 to 4 days after the onset of TEN the patient is given general
anesthesia for washing the wounds vigorously and applying briobrane under
tension to be stapled all over".
George Goris, Managing Director Medical and Drug Information of Pharmacia and
Upjohn expressed that "DEPO" dosage of more than the approved
indication, that too 80 mg twice daily, was not correct.
Fine, Dermatologist from University of North Carolina opined as under:
conventional therapy of TEN with systemic corticosteroids involves either oral
or intravenous preparation. I have personally never seen intramuscular
corticosteroids administration for this condition. In addition, intramuscular
corticosteroids are never given on a BID schedule (and with some preparations
no more frequently than every 4-6 weeks) because of the prolonged Depot effect
related to administration by this particular route. In general, intramuscular
administration of systemic corticosteroids is not employed in the treatment of
dermatological 57 diseases since this routes provides very erratic release of
medication from the tissue....."
remarked, as far as the treatment in the present case is concerned:
.... manner in which the treatment was instituted in your wife certainly
appears to be unprecedented."
Heimbach, Professor of University of Washington holds the view that the
injection "DEPO" in twice daily dose was not indicated in TEN
protocol and the dosing interval as advised in the prescriptions of the
opposite party no. 1 is not recommended for treatment of any medical condition,
leave aside for, far less an acute medical condition such as the one the
patient was suffering from i.e. TEN.
Timothy Bradley, noted Physician wrote a famous article on TEN wherein it was
stated that several patients of TEN with 95% total BSA involvement were treated
without use of steroids and there was 100% survival rate. In his view, the
keystone, for survival in patients with TEN is fluid resuscitation and
nutritional support and vigilant surveillance for infection.
Pierard in his treatise on TEN stated:- a) Antiseptic measures are essential to
treat TEN patients since septicaemia shock is the first cause of mortality. So
a sterile room and antiseptic bathes have to be used. Intact blisters can be
left in place but when they burst, the narcotic skin must be eliminated otherwise
it becomes an excellent medium for the proliferation of microorganisms.
skin swabs should be done to detect excessive coetaneous infection and to guide
antibiotics should also be used if direct or indirect signs of septicaemia
happen: positive blood cultures, pneumonia, decrease of the urinary flow, fever
or rapid fall of the temperature, impairing of the general condition, and
decrease in the white cells count with neutropenia. The search of these signs
implies a permanent patient's supervision with many blood takes. Of course,
unnecessary i.v. catheters should be avoided but in practise it is impossible
to totally avoid them. They have to be changed frequently and placed in culture
Supportive measures are also essential.
litres of fluid per day are needed since fluid loss is enormous in severe
cases. The absence of substitution of these fluids leads to important internal
problems. The only way to bring such amount of fluid is by catheters. The oral
59 way is absolutely inadequate, more especially as digestive tract is also
often injured. Once more, as previously said, catheters should be changed very
regularly (maximum every 3 days), placed if possible in areas of intact skin
and examined for bacterial contamination after removal.
definite TEN drug treatment is currently not recognised. The case of systematic
steroids is controversial. The use of high doses of quick acting
corticosteroids for a short time could be defensible for patients treated at
the beginning of TEN without any sign of septic contamination, to try to stop
the advancement of the disease. Steroids are clearly harmful and ineffective
when the disease has settled. Long-acting steroids have no place in TEN
treatments. Their action is too late.
slough of the skin and mucous membrane is painful and it is medical and ethical
concern to relief pain in TEN."
attention has also been drawn to the resolutions adopted in the year 1985 at
Creteil in France. We would label it as `Creteil Experience'. It is summarized
The absence of dermal inflammatory infiltration in TEN is an argument against
steroid therapy. Certain authors have claimed that the extension of necrolysis
is arrested by high-dose corticosteroid therapy, but the natural history of TEN
is very variable both in extent and time course. In some cases nerolysis is
complete within 24 hours. Clearly, steroid therapy is illogical in such
patients. In other patients, necrolysis may occur in waves. The unpredictable
course of the disease casts further doubt on uncontrolled claims of the
efficacy of steroid therapy. The benefits of steroid therapy, if any, would be
observed only at an early stage of a slowly evolving case of TEN. It cannot be
overemphasised that once a large area of dermis is uncovered i.e. more than 20%
of the body surface area, the supposed advantages of steroid-therapy are far
outweighed by its drawbacks. The opinion that steroids should not be used as a
standard therapy for TEN is shared by the majority of authors and was
unanimously agreed on at an international workshop on TEN held in Creteil,
France in October 1985. More recently, Halebian et al have reported high
improvement of survival in patients treated without steroids when compared with
a previous series of patients treated with high dose steroid therapy in the
also consulted several doctors and experts in India. We would notice the
opinion of some of them here but we would deal with their admissibility at a
Bose from Apollo Hospital, Delhi, on a query made by the appellant, opined that
the treatment protocol should be symptomatic and 61 corticosteroids should be
avoided. The resume of the protocol which should be followed, according to him,
is as under:
Discontinue all drugs implicated in TEN JAAD 1991 - Intravenous canalization
for fluid replacement depending upon % of TBSA, Nasogastric tube feeding,
catheter if required - Topical skin care - Monitoring serum electrolytes by
culture - Room Temperature of about 30-32 degrees Celsius, sterile environment,
air fluidized bed, barrier nursing - Encourage oral fluids - Hyperbaric oxygen,
aerosols, bronchial aspiration, physical therapy, therapies for herpes and
also consulted those Indian doctors who still administered steroids. Dr. J.S.
Pasricha is one of them. According to him, use of corticosteroids in TEN was
very controversial; however, if they are used appropriately, the patient's life
can be saved. Death due to usage of corticosteroids in TEN patients, he stated,
occurs only when :
reaction is not controlled properly - Corticosteroids are not withdrawn quickly
Attention has also been drawn to the protocol treatment on behalf of the
respondents. They have placed reliance on a number of authorities to 62 suggest
a protocol of treatment of the disease TEN in which the administration of
glucocorticosteriods plays an integral role. Some of the authorities suggested
by them include:
of Association of Physicians of India.
Comprehensive Dermatological Drug Therapy.
Dermatology by O. Brian Falco.
Dermatology in General Medicine (Fitz Patrick) (5th Ed) - Goodman and Gillman:
The Pharmacological Basis of Therapuetics (9th) (Ed) - Harrison's Principle of
Internal Medicine - Principle's of Pharmacology.
of Burn Care and Rehabilitation ( A 10 year experience with TEN) - TEN -
Medical Findings and Prognosis in 87 Patients, Jean Revuz, From the archives of
Dermatology - J.S. Pasricha, TEN, International Journal of Dermatology.
the following principles are integral to the treatment of TEN as suggested by
Treatment in burn units should be strived for in exceptional cases but is not
Treatment has to be individually tailored according to cause, type, stage and
presence of complications.
Systemic glucocorticoids should not be used routinely but are justified in the
early stages of drug induced TEN. They should be given in doses from 80 to 120
mg of methlypredisolone per day by mouth, for several days until disease
progression has ceased. Dosages should be tapered quickly and cautiously since
no further benefit can be expected thereafter and the untoward effects may then
Treatment may focus on early detection and prevention of the most fatal
complication e.g. overwhelming infection. Cultures from skin and mucosal
erosions, must be regularly performed.
gases and fluid, electrolytes and protein balance must be monitored and
adjusted appropriately. Fluid replacement regimens as used for burn patients.
Supportive care is of great importance and particular attention must be paid to
a high calorie and high - protein diet.
Debridgement of necrotic skin should not be performed before disease activity
criminal case, the appellant examined Dr. Salil Kumar Bhattacharjee. For the
sake of completeness it would be necessary to place on record his opinion in
Bhattacharjee, as noticed hereinbefore, is a Professor of Pharmacology at the
Institute of Medical Science, Benaras Hindu University. In an answer to a
query, on whether he was aware of the drug Depomedrol and its usage, he
answered that "it is usually used in chronic clinical condition like
Bronchial Asthma and Rheumatiod Arthritis" and on being questioned,
whether Depomedrol can be used for TEN, he answered in the negative. He stated
that recommended usage is 40 to 120 mg at intervals of at least one week and a
daily dose of 80 mg can never be used.
also examined Dr. Udwadia. He is the Consultant Physician in the Breach Candy
Hospital. Anuradha was a patient in the said hospital under him. He has not
used Depomedrol although his personal view was that he would have used lesser
doses of corticosteroid. Although he had not used Depomedrol and he had no
experience with the said drug, he 65 categorically stated that it could
obviously add to steroid. In his statement, he made it clear that "all corticosteroids
are double-edged weapons on the one hand, there can be a beneficial effect and
on the other, they can have untoward effects and the effect is
immunosuppression leading to infection".
testified that supportive therapy was necessary.
criminal case, even Dr. Prasad who was examined as PW-3 stated that he
prescribed Depomedrol for a day after seeing the prescription of Dr. Mukherjee.
And before the National Commission he stated that Depomedrol 80 mg twice daily
cannot be administered to any patient.
the Commission Dr. Mukherjee admitted that he prescribed the injection of
Depomedrol and gave it to the patient at the request of Kunal on compassionate
grounds. Dr. Halder accepted that Depomedrol is not the correct medicine for
TEN and is used in acute medical condition.
in view of the difference of opinion amongst experts as noticed by us
heretoabove in some detail, proceed on the assumption that steroid can be
administered in the TEN patients. However, it is clear from the opinion of the
pro-steroid experts that:
nature of steroid which should be used is corticosteroid meaning thereby methyl
It should be used only at the early stages for a few days and then should be
stopped or tapered to avoid the effect of immunosuppresion as also sepsis.
Supportive treatment must be administered.
should be individually tailored according to the patients' need.
treatment is also advised by Dr. Pasricha and others.
however, must be noticed at this juncture :
chemical composition of Depomedrol is different from other type of
glucocorticosteroid inasmuch as Depomedrol is methyl prednisolone acetate and
glucocorticosteroid is methyl prednisolone sodium succinate. The evidence of
Kunal in this behalf is absolutely categorical and unequivocal.
the authors are one in stating that their opinion is subject to the
instructions given in the package insert of the medicine.
examined Dr. Anil Shinde as PW-8. He is the Manager, Medical Service of
Pharmacia India Private Limited. Depomedorol is manufactured by Pharmacia and
Upjohn, USA. The company is the 67 distributor of the said product in India.
The packet insert of Depomedrol reads as under:
The usual dosage for patients with Dermatalogic Lesions benefitted by systemic
corticoid therapy is 40-120 MG of Methyl Prednisolone acetate administered
intramuscularly at weekly intervals for 1-4 weeks. In acute severe dermatitis
due to poison IV relief may result within 8-12 hrs following intramuscular
administration of a single dose of 80-120 MG. In chronic Contact dermatitis,
repeated injections at 5-10 day intervals may be necessary. Following
intramuscular administration of 80-120 MG to asthmatic patient's relief may
result within 6-48 hrs and persist for upto 2 weeks.
dosage will vary with the condition being treated when a prolonged effect is
weekly dose may be calculated by multiplying the daily dose by 7 and given as a
singular intramuscular injection. Dosage must be individualised according to
the severity of the disease and the response of the patients. In general, the
duration of the treatment should be kept as short as possible. Medical
surveillance is necessary.
After a single IM injection of 40-80 MG of Depomedrol, duration of HPA Axis
suppression ranges from 4-8 days. An intra-articular injection of 40 MG in both
knees given after 4-8 hrs methyl 68 prednisolone peaks of approximately 21.5
micrograms/ 100 ML. After intrarticular administration, methyl prednisolone
acetate defuses from the joint into systemic circulation over approximately 7
days as demonstrated by the duration of HPA Axis suppression and by the serum
Methyl Prednisolone Values.
For Intramuscular administration, Methyl Prednisolone acetate (Depomedrol) is
not suitable for the treatment of acute life threatening conditions if a rapid
hormonal effect of maximum intensity is required the IV administration of
highly soluble methyl prednisolone sodium succinate (Solumedrol) is indicated.
Since the complications of treatment with glucocorticoids are dependent on the
size of the dose and the duration of treatment ,a risk/ benefit decision must
be made in each individual case as to dose and duration of treatment and as to
whether daily or intermittent therapy should be used.
may musk some signs of infection and new infections may appear during their
be decreased resistance and inability to localise infection when
glucocorticoids are used.
69 Do not
use intrarticulary, intra bursally or intra tendinous administration in the
presence of acute infection. IM administration can only be considered after
institution of an appropriate anti microbial treatment."
necessity of following the instructions given in the packet insert cannot be
underestimated. Admittedly, the instructions in the said packet insert had not
been followed in the instant case.
EXCESS DOSAGE There is, thus, a near unanimity that the doses of
glucocorticosteroid and in particular Depomedrol were excessive. From the
prescription of Dr.
it is evident that he not only prescribed Depomedrol injection twice daily, but
had also prescribed Wysolone which is also a steroid having the composition of
AMRI records, it would appear that while admitting the patient, it had
categorically been noticed that both Depomedrol injection twice daily and
Wysolone were being administered from 7th May, 1998 following the prescription
of Dr. Mukherjee. It also now stands admitted that Dr. Prasad also prescribed
the same medicine. From Dr. Mukherjee's prescription dated 11.05.1998, it is
furthermore evident that he had 70 prescribed Wysolone 50 mg once daily for one
week, 40 mg daily for next week and 30 mg daily for the third week. He had also
prescribed Depomedrol injection 80 mg twice daily for two days.
is a "long acting" steroid recommended for the treatment of
"chronic" clinical conditions like "asthma" or
"arthritis" for its prolonged immnumosupressive action. The maximum
recommended dose of Depomedrol is 40-120 mg at 1-4 week intervals as clearly
mentioned by the drug manufacturer, Pharmacia. Dr. J.S. Pasricha, Prof.
and Ex -
head of Dermatology at the All India Institute of Medical Sciences (AIIMS) has
categorically stated, "Depo - preparations are used for chronic diseases
and not for acute disease like TEN. Secondly, Depo preparations are not to be
used twice a day".
deposition, Dr. Anil Gupta deposed that, he wrote to Pharmacia Upjohn, to know
from them if the drug can be used in this fashion (as was done by the Kolkata
doctors) in any clinical condition. In the reply sent by Dr. S.P.S. Bindra, it
was stated that "our package insert on Depomedrol does not recommend the
twice daily dose of injection Depomedrol 80 mg in any clinical condition".
Moreover he also testified to the cause of Anuradha's death was due to
Septicemia, which happened as a result of profound 71 immuno - suppression,
caused by overuse of steroid as prescribed by Dr. Mukherjee. Further cause of
death of Anuradha was lack of supportive treatment and lack of care on the part
of Dr. Abani Roycoudhuri and Dr. Halder and other attending Physicians.
deposition Dr. Anil Shinde stated that he was working as a Manager, Medical
Service with Pharmacia India Pvt. Ltd and elucidated the details of Depomedrol.
He stated that the dosage should be between 40 to 120 mg once a week or once in
two weeks. On questioned whether 80 mg of Depomedrol can be given twice daily,
the answer was "No".
deposition Dr. Salil Kumar Bhattacharya stated that he was a ] Professor of
Pharmacology. On being questioned whether he is aware of the Drug Depomedrol
and its usage, it was answered that "it is usually used in chronic
clinical condition like Bronchial Asthama and Rheumatoid Arthritus". On
being questioned whether Depomedrol can be used for TEN, the answer was
"No" He furthermore stated that the recommended usage is 40 to 120
mg. at intervals of at least 1 week and a daily dose of 80 mg can never be
used. On the question whether `long acting' steroids can accumulate in the
body, he replied `Yes, it can accumulate.' On being questioned, whether it is
discretion of the Physician to decide the mode of 72 administration of any
drug, he answered that the choice is "prerogative".
he has to follow the pharmaco- therapeutic norms of the drug chosen.
THERAPY No symptomatic therapy was administered. No emergency care was
provided. Dr. Halder himself accepted that the same was necessary. This has
also been stated by Roujeau and Revuz in their book in the following terms:
of any suspect drug, avoidance of skin trauma, inserting a peripheral venous
line, administration of macromolecular solution, direct the patient to burn
unit or ICU."
records demonstrate how abysmal the nursing care was. We understand that there
was no burn unit in AMRI and there was no burn unit at Breach Candy Hospital
either. A patient of TEN is kept in ICU. All emphasis has been laid on the fact
that one room was virtually made an ICU.
Restrictions were strictly adhered to. Hygiene was ensured.
constant nursing and supervision was required. In the name of preventing
infection, it cannot be accepted that the nurses would not keep a watch on the
patient. They would also not come to see the patients or 73 administer drugs.
No nasogastric tube was given although the condition of mouth was such that she
could not have been given any solid food. She required 7 to 8 litres of water
daily. It was impossible to give so much water by mouth. The doctors on the
very first day found that condition of mouth was bad.
specialist in his prescription noticed blisters around the lips of the patient
which led her to difficulty in swallowing or eating.
sample was taken. No other routine pathological examination was carried out. It
is now beyond any dispute that 25-30% body surface area was affected (re.
prescription of Dr. Nandy, Plastic Surgeon) The next day, he examined the
patient and he found that more and more body surface area was affected. Even
Dr. Prasad found the same.
therapy or symptomatic therapy, admittedly, was not administered as needle
prick was prohibited. AMRI even did not maintain its records properly. The
nurses reports clearly show that from 13th May onwards even the routine
check-ups were not done.
TREATMENT 74 Kunal and Anuradha came on a vacation to Calcutta on 1st April,
1998, principally to attend a wedding in the family. Anuradha supposedly, after
eating some Chinese food in some restaurant, developed fever and skin rash on
or about 25.4.1998. Respondent No.1, Dr. Sukumar Mukherjee, indisputably is a
very reputed Physician. He was a Professor of Medicine in Calcutta Medical
College. Anuradha and Kunal were advised to consult him.
No.1 examined Anuradha at her residence in the evening of 26th April, 1998. He
suggested certain pathological examinations. On that date no medicine was
prescribed. Two weeks thereafter i.e. on or about 7th May, 1998, Respondent
No.1 was informed by Kunal Saha that Anuradha's condition had deteriorated and
the skin rash and fever were back. She was taken to his chamber at 11, Shakespeare
rash, palpable penpina, enlarged neck glands were found to be present. She was
diagnosed to be suffering from `Anglo-Neurotic Oedema with allergic
vasculitis'. Respondent No.1 prescribed Depomedrol stat (immediately) injection
80 mg. on a twice daily schedule(B.I.D) for 3 days to be followed by other oral
steroids. One injection was given by him.
the institution of Depomedrol, Anuradha's condition worsened from bad to worse
in the next few days and Dr. Kunal Saha, 75 contacted Respondent No. 1 from
time to time for advice on telephone, who, however, insisted on continuing
Depomedrol in the same dose. Anuradha was said to have also examined by two
Consulting Dermatologists - Dr. A.K. Ghoshal and Dr. S. Ghosh, who diagnosed
disease to be a case of Vasculitis. The injection, as suggested by Respondent
No.1, however, was continued to be given.
about 11th May, 1998 Respondent No.1 was informed by Kunal that his wife's
condition had not been improving. The skin rash was persisting alongwith the
fever and palpable neck glands whereafter he was recommended that Anuradha be
hospitalised immediately. On the same date Anuradha was admitted in the
Advanced Medicare Research Institute (AMRI) (Respondent No. 4). On being
admitted she was examined by Dr. Balaram Prasad, Respondent No.5, who also
continued with the injection of Depo-Medrol 80 mg.(2 ml.) I/M B.D. x 1 day.
was examined by Respondent No.1 at 2.15 p.m. on the same date. The prescription
provided for Inj. 'Depomedrol' 80 mg IM twice daily x 2 days (then 40 mg IM
twice x days) among other things.
76 On the
basis of the said advise Anuradha was examined by Consultant Dermatologist Dr.
A.K. Ghoshal. Anuradha was diagnosed to be suffering from TEN. The bed ticket
reads as under :- "Toxic Epidermal Necrolysis.
of large sheets of skin from back and limbs, many small/ large bulla on limbs.
Dusky red areas of vasculitis almost all over the body. Mild conjunctivitis.
Erosive lesions on tongue and buccal mucosali.
fluid and electrolyte balance.
cream to apply on rash areas only Capsule Zevit - 1 Cap daily To be reviewed
No.3, Prof. Dr. Abani Roy Chowdhury, Consultant, as recommended by Respondent
No.12 was also consulted on 12th May, 1998.
however, stated that he did not examine the patient as he had not been
contacted by the hospital. Anuradha was also examined by Respondent No.2, Dr.
Baidyanath Halder, a Consultant Dermatologist of fame and author of several
Books on Skin Disorders. He also diagnosed that it could be a case of TEN. He
recommended treatment with Steroids like Pedmeslan and and others and the
application of ointments. Dr Halder found that 77 Anuradha was suffering from
Erithima plus blisters. However, no abnormality in the eyes or lungs was
detected. He, although opined that an electrolytic balance of the patent should
be maintained and steps should be taken to prevent any secondary infection, but
did not prescribe any medicine or indicated the steps to be taken therefor.
Prasad referred the patient to the following Consultants.
K. Nandy - a Plastic Surgeon ;
Purnima Chatterjee - a Gynecologist ;
S. Ahmed - an E.N.T. Surgeon ;
S. Bhattacherjee ; and (v) Dr. N. Iqbal - General Surgeon.
condition deteriorated further. On or about 17th May, 1998 Kunal was advised to
shift Anuradha to Breach Candy Hospital, Mumbai. For the aforementioned purpose
Respondent No.2 issued a certificate. Three words in the said certificate,
namely - "for better treatment" were said to be added.
Chartered Plane was arranged for taking Anuradha to Mumbai from Kolkata on 17th
May, 2009. She was admitted in the said hospital at about 78 9.30 p.m. On her
admission to the Breach Candy Hospital, it was recorded inter alia :-
"Mrs. Anuradha Saha has been admitted to Breach Candy Hospital, on 17.5.98
at night - 9.30 PM. Her condition on admission is serious. She has been
accompanied by her husband Dr. Saha, who has given the history of antibiotic
injection for respiratory tract injection - Rovamycin, Routhromycin, Ampicillin
and Ampiclox and Nemuslide followed by development of Toixc Epidermal
Necrolysis. She has received T Prednisolone 120 mg/day for 7 days and also Inj.
Im x 3 days. She has been hemodynamically stable till now. She is able to
swallow liquids, which has been her only nourishment over the past few
examined by Dr. Farokh E. Udwadia at the Breach Candy Hospital in the afternoon
of 18th May, 1998. His diagnosis was as under :- "Patient has come with a
diagnosis Toxic Epidermal Necrolysis (TEN). She has had a number of drugs at
Calcutta form antibiotics to non-steroid and inflammatory agents. Is there any
way of distinguishing this from a Stevens & Johnson Syndrome? There is no
skin left. The mucus of the mouth, genitals and area is also severely affected.
not seen the evolution of the skin lesions to the point where there is now no
skin left. So far there is no organ evolvement in particular. No pulmonary
lesions nor any urinary lesions (organs commonly involved as in a Steven
Johnson Syndrome). In any case the basic management is the same. I do feel that
the dose of steroids used in 79 Calcutta is either excessive - 120 mg. Daily
for a number of days, preceded by 80 mg Depomedral Injections. I would not give
more than 40 mg /day Kg. body weight."
same date Kunal's brother who is also a doctor practicing in U.S.A. flew to
Mumbai. He brought with him a new antibiotic known as "Quinolone".
There was some difference of opinion between the brother-in- law of Anuradha
and Dr. Udwadia, which was noted by Dr. Udwadia. It reads as under :- "He
was claiming of blood transfusion - insisted that his blood or the relatives or
friends blood be used - no objection. But I have requested that this is done
quietly. The advice was to give whole blood. My view is that `blood' is being
used to increase Hb., and it is unusually accepted that to do so one gives
packed cell and not whole blood.
also advising the use of Erthropoitin as a marrow stimulant. My view was that
at the point of time Erythropeitin will make no difference to her condition. To
increase her Hb., from the present and Requested packed RBC infusions.
keen on immediately giving a tonic supplement. In my experience at this point
of time, Zinc supplement was not of immediate importance that if gut was
working and her external feed could be increased, she would receive sufficient
However, some differences between Kunal and his elder brother on one hand and
Dr. Udwadia persisted. He noted as under :- "Have had great problems with
the husband and brother-in-law. It is with great difficulty that I have
controlled myself. When presented with his arrogance and condescends - merely
and solely for the patient's sake. To keep the peace, I have compromised on the
the use of Erythropoeitin. I reasoned that though it cannot do much good, it
does not do harm.
the use of a Zinc preparation - totally unnecessary but not likely to lead to
not allow parental alimentation through the same central line as fluids and
electrolytes as I feel that gut if viable used at IV alimentation at this point
of time may add to her hazards".
condition was better during 24th May and 25th May, 1998. She, however, breathed
her last on 28th May, 1998.
infections are infections which are a result of treatment in a hospital or a
healthcare service unit, but secondary to the patient's original condition.
Infections are considered nosocomial if they first appear 48 hours or more
after hospital admission or within 30 days after discharge. Thus it 81 becomes
the liability of the hospital to prevent such infection specially in the cases
where the patient has high risk of infection due to the nature of disease
also the other respondents say that the room was made infection free. Certain
restrictions on the visitors had also been taken. It is, however, not disputed
that the dressing of body surface by Dr. Kaushik Nandy started only on 13th
May, 1998. What type of dressing was to be done is a matter of dispute. We may
not go into the said question. But, we must notice that in Breach Candy
Hospital, the dressing was done in operation theatre, firstly, on 18th May,
1998 and then on all subsequent days.
dressing was done at AMRI in operation theatre.
It is now
almost accepted worldwide that the hospital is liable to prevent such
infections specially in the case where the patient has high risk thereof due to
the nature of the disease suffered. It also almost stands established that use
of Depomedrol and other high dose of glucocorticosteroid may first lead to
immunosuppression which may in turn lead to septisis.
April, 1998, when she started suffering, she had skin rash. By the time, she
came to AMRI on 11th May, 1998, 25-30% of body surface area was infected.
Admittedly, by 14th May, 1998, her entire body except the skull denuded of
skin. Plastic Surgeon at Breach Candy Hospital who had been doing the dressings
on 19th May, 1998 stated that green tinge had appeared on the back. Such a
green tinge would not occur within a day.
infection was widespread. It might have been controlled to some extent at
Breach Candy Hospital. In the said hospital, the entire body was put in bandage
without leaving any part of the body open. It is only with a view to control
such bacterial infection, the antibiotics were administered.
FINDINGS AND ANALYSIS WITH RESPECT TO SO CALLED CLEAVAGE OF OPINION FINDINGS ON
SO CALLED CLEAVAGE OF OPINION Appellant, thus, has placed on record the view
points of experts - both of the pro-steroid and anti-steroid group. Would it
amount to cleavage of opinion so as to enable the court to arrive at a safe
conclusion that no negligence is proved or there was no deficiency in service?
In other words, the question is as to whether the treatment of Anuradha was in
accordance with the medical protocol. In our opinion, the answer must be
rendered in 83 the negative. Those who support use and administration of
steroid do so with note of caution. They in no uncertain terms state that the
same should be used at a preliminary stage. Respondents do not spell out as to
what would be the preliminary stage. The preliminary stage must have started
with the onset of the disease. She had been suffering from skin rash from 3rd
week of April, 1998. It increased with the passage of time. The cause of such
eruption was not ascertained. In fact what caused the onset of disease was not
known. It may be from Chinese food or it may even be from use of vitamin.
from 7th May, 1998, she was prescribed injection Depomedrol twice a day and
Wysolone. It was continued upto 13th May, 1998, nobody even thought of stopping
the injection. Dr. Halder although stopped Depomedrol injection from 13th May,
1998, but prescribed a high dose of steroid.
posed unto themselves a basic question why despite use of steroid, condition of
the patient was going from bad to worse. It is agreed across the board and at
least during trial, that supportive treatment should have been given. The
medicine was propagated which did not exist. The medical literatures were not
consulted. Even for pulse therapy Depomedrol could not have been used and only
Solumedrol could have been used. Kunal 84 in his evidence explained the
difference between the two. Dr. Mukherjee in his deposition indirectly accepted
the same. Each of those pro-steroid group spoke of a single injection. Nobody
suggested on the face of the voluminous medical literature and authoritative
opinions of the experts that two injections daily could be prescribed by any
prudent physician. A great deed of confusion was sought to be created between
one kind of steroid and another. Vague questions were asked from the experts to
show that steroids may be used but Dr. Pasricha stated that only a quick acting
steroid should be used. Depomedrol is not a quick acting steroid.
his evidence categorically stated so in the following terms:
can be used daily at 200 mgs for multiple sclerosis. But if instead of
Prednisolone, Depomedrol which is Methyl Prednisolone Acetate is used to this
patient he or she is likely to die.
is not Prednisolone. And majority of the dermatologists in the West do not do
not use any steroid whatsoever on TEN patients."
there is no controversy even among the "Pro-steroid" dermatologists
that once more than 20% of the BSA is affected no steroid should be used as it
would only enhance the chance of development of septicemia and death."
85 The High Court as also the Commission principally proceeded on the premise
that the respondents herein are not liable either for any act of criminal
misconduct or negligence because of cleavage of opinion. The cleavage of
opinion, if any, as we have noticed hereinbefore, is between pro- steroid group
and anti-steroid group. Accepted treatment protocol so far as the pro-steroid
group is concerned has also been noticed by us. We have proceeded to determine
the question of negligence on the part of the respondents herein principally on
the premise that even if the opinion of the pro-steroid group is followed, the
respondents have failed and/or neglected to even act strictly in terms of the
treatment protocol laid down by them.
opinion of the anti-steroid group appears to be more scientific and structured
but the same by itself, we are conscious of the fact, would not lead us to the
conclusion that the respondents are guilty of gross negligence.
however, notice that Mr. Fitz Patrick in his book Dermatology in General
Medicine (5th Edition), inter alia, opined as under:- "Treatment:
According to our view, agreement should be used on following for the treatment
Treatment in burn units should be strived for in exceptional cases but is not
Treatment has to be individually tailored according to cause type and stage and
presence and type of complications.
Systemic glucocorticoids should not be used routinely but are justified in the
early stages of drug induced TEN. They should be given in doses from 80 to 120
mg of methlypredisolone per day by mouth, for several days until disease
progression has ceased. Dosages should be tapered quickly and cautiously since
no further benefit can be expected thereafter and the untoward effects may then
Treatment may focus on early detection and prevention of the most fatal
infection. Cultures from skin and mucosal erosions, must be regularly
gases and fluid, electrolytes and protein balance must be monitored and
adjusted appropriately. Fluid replacement regimens as used for burn patients.
Supportive care is of great importance and particular attention must be paid to
a high calorie and high - protein diet.
Debridgement of necrotic skin should not performed before disease activity
and Prognosis: The following factors appear to be unfavourable prognostic
signs: old age, extensive skin lesions, nuetropenia, impaired renal function
and intake of multiple drugs. Septesemia, gastrointestinal hemorrhage,
pnuemoina and fluid and electrolyte imbalance leading to 87 renalinsufficiency
are major complications leading to death."
noticed hereinbefore, precautions as also the course of actions suggested by
the authors have not been undertaken by the respondents. It is to be noted that
the learned authors' expertise in the field is neither in doubt nor in dispute,
particularly when both parties have extensively relied thereupon. Even the
suspected offending drug was not withdrawn at later stages. This drug is
considered to be a real risk for the patient suffering from TEN. The medicine
has also been administered having regard to the physical condition of the
patient. They were required to be given only as a part of the total program. We
may also place on record that there has been a cleavage of opinion in regard to
mortality rate. Whereas according to the one group of experts in TEN patients
when properly treated and in particular given supportive treatment, the
mortality rate is 0-10%' the respondents contend that that in fact the
mortality rate is quite high being 30-70%.
assume that the mortality rate is very high. If that be so, we feel that the
doctors should have been more careful. They should have treated the patient
upon exercise of more care and caution. For the said purpose, if they had not
been able to diagnose the disease properly or identify the proper drug they
would have undertaken some research. It is 88 clear that they did not have any
expertise in the field and therefore they ought not to have behaved as experts
We are, therefore, of the opinion that the universally accepted medicated
treatment protocol had also not been followed.
also to be noted at this juncture, that there may well be a difference of
opinion on the course of action to be adopted while treating a patient of TEN,
but the treatment line followed by Dr. Mukherjee which entailed administration
of 80 mg of Depomedrol injection twice is not supported by any school of
thought. The treatment line, in this case, does not flow from any considered
affinity to a particular school of thought, but out of sheer ignorance of basic
hazards relating to use of steroids as also lack of judgment.
BURDEN OF PROOF Kunal had not only obtained opinion of a large number of
experts, he examined some of the including Dr. Anil Shinde P.W. 9,; Dr. Udwadia
(P.W.10) and, Dr. Salil Kumar Bhattacharyya, P.W. 11.
did not examine any expert. They, however, relied upon some authorities to
which we have referred to heretobefore. The onus of proof, therefore, on a situation
of this nature shifted to the respondents.
we say so we must place on record that we are not oblivious of the fact that
the principle of res ipsa loquitur may not be strictly applicable in a criminal
case, although certain authorities suggest application of the said principle.
Meadows Hospital v. Harjol Ahluwalia, [(1998) 4 SCC 39], this Court has held as
under :- "10. Gross medical mistake will always result in a finding of
negligence. Use of wrong drug or wrong gas during the course of anaesthetic
will frequently lead to the imposition of liability and in some situations even
the principle of res ipsa loquitur can be applied. Even delegation of
responsibility to another may amount to negligence in certain circumstances. A
consultant could be negligent where he delegates the responsibility to his
junior with the knowledge that the junior was incapable of performing of his
in Rattan Singh v. State of Punjab, [(1979) 4 SCC 719}, this Court has held :-
"3. This, however, does not excuse the accused from his rash driving of a
"blind Leviathan in berserk locomotion". If we may adapt the words of
Lord Greene, M.R. : "It scarcely lies in the mouth of the truck driver who
plays with fire to complain of burnt fingers". Rashness and negligence are
relative concepts, not absolute abstractions. In our current conditions, the
law under Section 304-A IPC and under the rubric of Negligence, must have due
regard to the fatal 90 frequency of rash driving of heavy duty vehicles and of
speeding menaces. Thus viewed, it is fair to apply the rule of res ipsa
loquitur, of course, with care. Conventional defences, except under compelling
evidence, must break down before the pragmatic Court and must be given short
from this angle, we are convinced that the present case deserves no
consideration on the question of conviction."
Nagabhushanam v. State of Karnataka, [(2008) 5 SCC 730],this Court held as
under :- "12. Reliance placed by Mr Kulkarni on Syad Akbar v. State of
Karnataka1 is not apposite. It proceeded on the basis that res ipsa loquitur
stricto sensu would not apply to a criminal case as its applicability in an
action for injury by negligence is well known. In Syad Akbar this Court opined:
41, para 30):
Such simplified and pragmatic application of the notion of res ipsa loquitur,
as a part of the general mode of inferring a fact in issue from another
circumstantial fact, is subject to all the principles, the satisfaction of
which is essential before an accused can be convicted on the basis of
circumstantial evidence alone. These are: Firstly, all the circumstances,
including the objective circumstances constituting the accident, from which the
inference of guilt is to be drawn, must be firmly established. Secondly, those
circumstances must be of a determinative tendency pointing unerringly towards
the guilt of the accused. Thirdly, the circumstances should make a chain so
complete that they cannot reasonably raise 91 any other hypothesis save that of
the accused's guilt. That is to say, they should be incompatible with his
innocence, and inferentially exclude all reasonable doubt about his
cannot, however, be any doubt whatsoever that in the civil appeal the said
principle is applicable. It has clearly been held by this Court that the onus
of proof would shift on the respondents.
Institute of Medical Sciences v. Prasanth S. Dhananka and others, [2009 (7)
SCALE 407] this Court held as under :- "32. We are also cognizant of the
fact that in a case involving medical negligence, once the initial burden has
been discharged by the complainant by making out a case of negligence on the
part of the hospital or the doctor concerned, the onus then shifts on to the
hospital or to the attending doctors and it is for the hospital to satisfy the
Court that there was no lack of care or diligence. In Savita Garg (Smt.) v.
Director, National Heart Institute it has been observed as under:
allegation is made that the patient was admitted in a particular hospital and
evidence is produced to satisfy that he died because of lack of proper care and
negligence, then the burden lies on the hospital to justify that there was no
negligence on the part of the treating doctor or hospital. Therefore, in any
case, the hospital is in a better position to disclose what care was taken or
what medicine was 92 administered to the patient. It is the duty of the
hospital to satisfy that there was no lack of care or diligence. The hospitals
are institutions, people expect better and efficient service, if the hospital
fails to discharge their duties through their doctors, being employed on job
basis or employed on contract basis, it is the hospital which has to justify
and not impleading a particular doctor will not absolve the hospital of its
CONTRIBUTORY NEGLIGENCE The High Court as also the Commission opined that the
death of Anuradha took place not because of any negligence on the part of the
doctors of AMRI but by reason of interference by Kunal Saha. It was on the
insistence of Kuanl Saha that the patient was transferred to Bombay. It has
been submitted that it was the infection which developed during transportation
which ultimately proved fatal.
by Kunal at AMRI was sought to be proved through Sutapa Chanda, Nursing
Superintendant at AMRI, who appeared as DW-1.
the statement of the said Nursing Superintendent in regard to the alleged
interference by Kunal is not borne out from the record. As a matter of fact she
had not been able to explain the medicines which were to be administered to her
stating:- 93 "Q.38 (Ld. complainant counsel sows the witness Exbt. 8).
What do you understand by this line "Fusys 200 mg. / weekly once"; -
3rd line from the end? Ans. Regarding this question I like to say all
instructions for mediction in Exbt. 8 were carried out by Dr. Kunal Saha but
not by my nurses. If I cannot understand this instruction I would have made
queries and doctor would clear it. But I had no such chance to make queries
It is to
be noted here that Nursing Superintendent being a professional cannot take this
plea. Moreover, the same is not borne out of records at AMRI. Even if we assume
this statement to be true, in a professional setting of this nature, these
interferences should have been resisted by them.
cannot be taken to be an excuse for abdicating one's responsibility especially
when an interference could also have been in the nature of suggestion.
comments were said to have been made by Dr. Halder while making his statement
under Section 313 of the Code of Criminal Procedure.
admissible in evidence for the said purpose. Similarly the statements made by
Dr. Mukherjee and Dr. Halder in their written statements before the National
Commission are not backed by any evidence on record. Even otherwise, keeping in
view the specific defence raised by 94 them individually, interference by
Kunal, so far as they are concerned, would amount to hearsay evidence and not
Nandy in his evidence stated that he was not allowed to change the dressings on
15th May and 16th May, 1998. However, according to him, he forced his decision
to do the dressing on 17th May, 1998 before she was taken away from the
it appears from the AMRI records that the name of Kunal only appears once i.e.
when he got Anuradha admitted in the hospital. His name is not borne out from
any other record. So far as the statement of Dr.
concerned, Kunal's explanation is that he did not follow the medical protocol
in the matter of dressing. This may or may not be correct.
notice that whenever any interference in contrast to the AMRI was attempted to
be made by the patient party at Breach Candy Hospital, it had scrupulously been
placed on record. Wherever "Dr. Saha"
in the record, it is evident that the same refers to the elder brother of
Kunal, who is a surgeon. However, when there is any discussion with both the
brothers, like in the case of Dr. Udwadia, it had been recorded `both of them'.
95 It is
accepted that the elder brother of Kunal came to Mumbai on 17th May, 1998
itself. He brought with him a new antibiotic named "Quinolone"
not available in India. He persuaded Dr. Udwadia to administer the said
injection. This discussion between them has also been recorded.
adverse remarks have also been recorded with regard to the conduct of Dr. Saha.
Dr. Udwadia has noticed in the records of the Breach Candy Hospital that he
tolerated the said conduct on the part of the elder brother of Kunal solely for
the patient's sake.
some of the suggestions of Dr. Saha did not seem particularly useful to Dr.
Udwadia, but those measures which were not harmful to the patient were administered.
We, however, may also notice that where Dr. Udwadia thought that there could be
some harm to the patient, he did not agree thereto. He, therefore, acted in a
also place on record that despite such elaborate and careful treatment meted
out to Anuradha, her condition had been worsening; Dr. Udwadia even agreed to
administer the injection "Quinolone" during her last day as he might
have thought that there was no harm in trying the same at that juncture.
also sought to highlight on the number of antibiotics which are said to have
been administered by Kunal to Anuradha while she 96 was in AMRI contending that
the said antibiotics were necessary. Kunal, however, submitted that the said
antibiotics were prescribed by the doctors at AMRI and he did not write any
prescription. We would, however, assume that the said antibiotics had been
administered by Kunal on his own, but it now stands admitted that
administration of such antibiotics was necessary.
it will be pertinent to note that even if we agree that there was interference
by Kunal Saha during the treatment, it in no way diminishes the primary
responsibility and default in duty on part of the defendants. In spite of a
possibility of him playing an over-anxious role during the medical proceedings,
the breach of duty to take basic standard of medical care on the part of
defendants is not diluted. To that extent, contributory negligence is not
pertinent. It may, however, have some role to play for the purpose of damages.
NON-JOINDER OF NECESSARY PARTIES Respondents contend that Dr. Kunal had been
selective in prosecuting three principal doctors on the criminal side who
allegedly treated Anuradha but some more before the Commission. Contending that
no reason has been assigned as to why case against Dr. A.K. Ghoshal has also
Breach Candy Hospital and doctors treating Anuradha at Bombay from 17th May,
1998 till 97 28th May, 1998 had been given up, the learned counsel urged that
these appeals should be dismissed on that ground alone.
afraid that the aforementioned submission cannot be accepted in view of the
decision of this Court in Smt. Savita Garg (supra), wherein it has been held:
far as the law with regard to the non- joinder of necessary party under Code of
Civil Procedure, Order 1 Rule 9 and Order 1 Rule 10 of the CPC there also even
no suit shall fail because of mis-joinder or non-joinder of parties. It can
proceed against the persons who are parties before the Court. Even the Court
has the power under Order 1 Rule 10(4) to give direction to implead a person
who is a necessary party. Therefore, even if after the direction given by the
Commission the concerned doctor and the nursing staff who were looking after
the deceased A.K. Garg have not been impleaded as opposite parties it cannot
result in dismissal of the original petition as a whole."
argument has also been advanced that Anuradha was treated by as many as 16
doctors and, thus, there was no reason as to why only the respondents should
have been proceeded against. Proceeding should be initiated both under the
criminal law as also the tort law only against those who are specifically found
to be guilty of criminal misconduct or medical negligence or deficiency in
service and not against all. Apart from making a 98 general submission, it has
not been pointed out as to what difference would have been made if others were
also impleaded as parties. The medical records were before the court. The
hospital records of both AMRI and Breach Candy were also before it. AMRI
records contained 22 pages, records of Breach Candy runs into more than 400
pages. No party had relied on any evidence other than those records as also the
oral evidence and documentary evidence brought on record by them. Respondents
have also not pointed out as to how treatment by any other doctor has
contributed in any manner to the death of Anuradha.
have also been made at the bar that Kunal issued notices to a large number of
persons but withdrew the cases against most of them. It was placed before us
that in the first notice there were as many as 26 addresses and in the
complaint filed before the National Commission, there were 19 addresses.
Withdrawal of cases against some of them, in our opinion, is not of much
significance. The Directors of AMRI were impleaded as parties. Cases against
them had also been withdrawn and, in our opinion, rightly so as most of them
were liable in their personal capacity.
says that the proceeding against Breach Candy Hospital and doctors treating
Anuradha had been withdrawn as the principal grievance against the hospital was
that they did not have any burn ward although he 99 was already informed
thereabout. Burn ward was also not there in AMRI.
it was brought on record that no nursing home in Calcutta has a separate burn
ward. Absence of burn ward by itself, thus, might not be a contributory factor
although existence thereof was highly desirable keeping in view the treatment
bear in mind that negligence is attributed when existing facilities are not
availed of. Medical negligence cannot be attributed for not rendering a
facility which was not available. In our opinion, if hospitals knowingly fail
to provide some amenities that are fundamental for the patients, it would
certainly amount to medical malpractice. As it has been held in Smt. Savita
Garg (supra), that a hospital not having basic facilities like oxygen cylinders
would not be excusable. Therein this Court has opined that even the so-called
humanitarian approach of the hospital authorities in no way can be considered
to be a factor in denying the compensation for mental agony suffered by the
parents. The aforementioned principle applies to this case also in so far as it
answers the contentions raised before us that the three senior doctors did not
charge any professional fees.
event, keeping in view of the said decision, we are of the firm opinion that
notices to a large number of persons and withdrawal of cases 100 against some
of them by itself cannot be considered to be a relevant factor for dismissal of
LIABILITY UNDER TORT LAW AS ALSO UNDER
case, we are concerned with the extent of negligence on the part of the
doctors, if any, for the purpose of attracting rigours of Section 304A of the
Indian Penal Code as also for attracting the liability to pay compensation to
the appellant in terms of the provisions of the Consumer Protection Act, 1986.
We intend to deal with these questions separately.
noteworthy that standard of proof as also culpability requirements under
Section 304 -A of Indian Penal Code stands on an altogether different footing.
On comparison of the provisions of Penal Code with the thresholds under the
Tort Law or the Consumer
Protection Act, a foundational principle that the
attributes of care and negligence are not similar under Civil and Criminal
branches of Medical Negligence law is borne out. An act which may constitute
negligence or even rashness under torts may not amount to same under section
304 - A. Bearing this in mind, we further elaborate on both the questions
LAW OF NEGLIGENCE UNDER TORT LAW Negligence is the breach of a duty caused by
the omission to do something which a reasonable man, guided by those
considerations which ordinarily regulate the conduct of human affairs would do,
or doing something which a prudent and reasonable man would not do. [See Law of
Torts, Ratanlal & Dhirajlal Twenty-fourth Edition 2002, at p.441-442]
Negligence means "either subjectively a careless state of mind, or
objectively careless conduct. It is not an absolute term but is a relative one;
a comparative term. In determining whether negligence exist in a particular case,
all the attending and surrounding facts and circumstance have to be taken into
account." [See Municipal Corpn. Of Greater Bombay v. Laxman Iyer, (2003) 8
SCC 731, para 6; Adavanced Law Lexicon, P Ramanatha Aiyar, 3rd ed. 2005, p.
3161] Negligence is strictly nonfeasance and not malfeasance. It is the
omission to do what the law requires, or the failure to do anything in a manner
prescribed by law. It is the act which can be treated as negligence without any
proof as to the surrounding circumstances, because it is in violation of
statute or ordinance or is contrary to the dictates of ordinary prudence.
Bolam v. Friern Hospital Management Committee, [(1957) 2 All ER 118], the law
was stated thus:
you get a situation which involves the use of some special skill or competence,
then the test.....is the standard of ordinary skilled man exercising and
professing to have that special skill.
need not possess the highest expert skill; it is well-established law that it
is sufficient if he exercises the ordinary skill of an ordinary competent man
exercising that particular art....
doctor] is not guilty of negligence if he has acted in accordance with a
practice accepted as proper by a responsible body of medical men skilled in
that particular art....Putting it the other way round, a [doctor] is not
negligent, if he [has acted] in accordance with such a practice, merely because
there is a body of opinion which [takes] a contrary view."
been laid down that an ordinary skilled professional standard of care for
determining the liability of medical professional should be followed.
Maynard v. West Midland Regional Health, Authority, [(1985) 1 All ER 635 (HL)])
Recently in Martin F.D' Souza v. Mohd. Ishfaq, [ (2009) 3 SCC 1], this Court
laid down the precautions which doctors/hospitals etc. should have taken, in
the following terms :- 103 "(a) Current practices, infrastructure,
paramedical and other staff, hygiene and sterility should be observed
prescription should ordinarily be given without actual examination. The
tendency to give prescription over the telephone, except in an acute emergency,
should be avoided.
doctor should not merely go by the version of the patient regarding his
symptoms, but should also make his own analysis including tests and
investigations where necessary.
doctor should not experiment unless necessary and even then he should
ordinarily get a written consent from the patient.
expert should be consulted in case of any doubt...."
the Bolam case in common laws jurisdictions is weakened in recent years by
reasons of series of decisions in Australia [Rogers v. Whitaker: (1992) 109 Aus
LR 625 and Roenbreg v. Percival 2001 HCA 18];
[Ribl v. Hughes: (1980) 114 DLR 3d 1] and the United States and even in the
refer to Bolitho v. City and Hackney Health Authority, [(1997) 4 All ER 771
(HL)], where the Court got away from yet another aspect of Bolam case. It was
observed :- 104 " The court is not bound to hold that a defendant doctor
escapes liability for negligent treatment or diagnosis just because he leads
evidence from a number of medical experts who are genuinely of opinion that the
defendant's treatment or diagnosis accorded with sound medical practice. The
use of these adjectives - responsible, reasonable and respectable - all show
that the court has to be satisfied that the exponents of the body of opinion
relied upon can demonstrate that such opinion has a logical basis. In particular
in cases involving, as they so often do, the weighing of risks against
benefits, the judge before accepting a body of opinion as being responsible,
reasonable and respectable, will need to be satisfied that, in forming their
views, the experts have directed their minds to the question of comparative
risks and benefits and have reached a defensible conclusion on the
regard it would be imperative to notice the views rendered in Jacob Mathew v.
State of Punjab, [(2005) 6 SCC 1, where the court came to the conclusions:
deviation from normal professional practice is not necessarily evidence of
accident is not evidence of negligence (iii) An error of judgment on the part
of a professional is not 7negligence per se.
Simply because a patient has not favourably responded to a treatment given by a
physician or a surgery has failed, the doctor cannot be held liable per se by
applying the doctrine of res ipsa loquitor.
THE PATIENT TO BE INFORMED The patients by and large are ignorant about the
disease or side or adverse affect of a medicine. Ordinarily the patients are to
be informed about the admitted risk, if any. If some medicine has some adverse
affect or some reaction is anticipated, he should be informed thereabout. It
was not done in the instant case.
Sidaway v. Board of Governors of Bethlem Royal Hospital and the Maudsley
Hospital, [  All ER 643 ], the House of Lords, inter alia held as under
:- "The decision what degree of disclosure of risks is best calculated to
assist a particular patient to make a rational choice as to whether or not to
undergo a particular treatment must primarily be a matter of clinical judgment.
whether non-disclosure of a particular risk or cluster of risks in a particular
case should be condemned as a breach of the doctor's duty of care is an issue
to be decided primarily on the basis of expert medical evidence. In the event
of a conflict of evidence the judge will have to 106 decide whether a responsible
body of medical opinion would have approved of non-disclosure in the case
might in certain circumstances come to the conclusion that disclosure of a
particular risk was so obviously necessary to an informed choice on the part of
the patient that no reasonably prudent medical man would fail to make it, even
in a case where no expert witness in the relevant medical field condemned the
non-disclosure as being in conflict with accepted and responsible medical
on medical negligence also has to keep up with the advances in the medical
science as to treatment as also diagnostics. Doctors increasingly must engage
with patients during treatments especially when the line of treatment is a
contested one and hazards are involved. Standard of care in such cases will
involve the duty to disclose to patients about the risks of serious side
effects or about alternative treatments. In the times to come, litigation may
be based on the theory of lack of informed consent. A significant number of
jurisdictions, however, determine the existence and scope of the doctor's duty
to inform based on the information a reasonable patient would find material in
deciding whether or not to undergo the proposed therapy. [See Canterbury v.
Spence, 464 F.2d 772 (D.C. Cir. 1972), cert. denied, 409 U.S. 1064 (19r72); see
also Cobbs v. Grant, 8 Cal. 3d 229, 104 Cal. Rptr. 505, 502 P.2d 1 (1972);
Hamiltorn v. Hardy, 37 Colo. 107 App. 375, 549 P.2d 1099 (1976)]. In this
respect, the only reasonable guarantee of a patient's right of bodily integrity
and self-determination is for courts to apply a stringent standard of
disclosure in conjunction with a presumption of proximate cause. At the same
time, a reasonable measure of autonomy for the doctor is also pertinent to be
safeguarded from unnecessary interference.
TRANSPORTATION So far as transportation of Anuradha from Kolkata to Mumbai is
concerned, we must place on record that a certificate in that behalf was given
by Dr. Baidyanath Halder correctness whereof, except for the words "for
better treatment" is not in dispute. Dr. Halder does not contend that the
contents of the same are wrong. He merely says that the same was issued at the
instance of the patient. The submission of Dr. Halder that he had issued the
certificate without seeing the patient cannot be believed. If that be so, such
a certificate could have been issued by Dr. Balram Prasad and/or any other
doctor. Why he had taken the burden of issuing such a certificate is not
We are of
the opinion that a conclusion as to whether the words "for better
treatment" have been inserted in the said certificate or not or the same
108 was done at the instance of Kunal, is wholly unnecessary for our purpose.
question which arises is as to whether there was any risk of Anuradha
developing infection due to exposure during transportation. She was flown to
Mumbai by an exclusive chartered flight (air ambulance) of East-West Rescue of
Delhi. Kunal had to pay about $ 2000 for the said purpose. Respondents did not
suggest that the service provided by the said airlines was of inferior
character or sufficient precautions were not taken during transportation. In
fact, the condition of Anuradha was so critical that there was no other option
but to take her to a better hospital. Her transportation to Mumbai was
necessary and was not an act borne out of desperation alone.
notice that even a couple of Kunal's friends, who were doctors, came to Mumbai
by Jet Airways flight.
appears that East West Rescue of Delhi, which provided air ambulance, must have
taken all necessary precautions. Although lot of literature on the subject
relating to the services of the said airlines showing that it is considered to
be one of best in the world is available, we refrain from dealing with the
same, as it is not necessary.
Udwadia made a comment that transportation of Anuradha from Kolkata to Mumbai
may have exposed her to infection. He, however, added 109 a proviso thereto -
unless better care was taken. There was no reason as to why the proper care was
not taken, particularly seeing her condition. There is no evidence on record
leading to an opposite conclusion. Dr. Nandy, stated dressing was necessary
before transportation. He must have done so keeping in view the necessity of
prevention of further infection during flight.
Bombay, Dr. Kulkarni noticed a green patch showing old infection. It must have
escaped the notice of even Dr. Nandy. Dr. Kulkarni noticing the same, observed
that the patient's condition was worse than he anticipated.
LEGITIMATE EXPECTATION Kunal approached the best doctors available. He admitted
his wife at AMRI on the recommendation of Dr. Mukherjee, evidently, expecting
the best possible treatment from the renowned doctors and a renowned hospital.
not too much for a patient to expect the best treatment from the doctors of the
stature of Dr. Mukherjee, Dr. Halder and Dr. Abani Roy Chowdhury. Services of
other experts in fields were requisitioned by the Hospital. References were
made and the Hospital on the basis of the recommendations made by the doctors
themselves consulted the best doctors in their respective fields. Kunal or
Anuradha or his relatives never interfered therewith. They did not call any
doctor of their choice to the Hospital. In fact, after Dr. A.K. Ghoshal came to
know that Anuradha was suffering from 110 TEN, he suggested a line of treatment
which was not adhered to keeping in view the fact that Dr. Halder and hospital
authorities were in charge of the case.
standard of duty to care in medical services may also be inferred after
factoring in the position and stature of the doctors concerned as also the
hospital; the premium stature of services available to the patient certainly
raises a legitimate expectation. We are not oblivious that the source of the
said doctrine is in administrative law. A little expansion of the said doctrine
having regard to an implied nature of service which is to be rendered, in our
opinion, would not be quite out of place.
makes a representation that it is one of the best hospitals in Calcutta and
provides very good medical care to its patients. In fact the learned Senior
Counsel appearing on behalf of the respondents, when confronted with the
question in regard to maintenance of the nurses register, urged that it is not
expected that in AMRI regular daily medical check-up would not have been
conducted. We thought so, but the records suggest otherwise. The deficiency in
service emanates therefrom. Even in the matter of determining the deficiency in
medical service, it is now well- settled that if representation is made by a
doctor that he is a specialist and 111 ultimately it turns out that he is not,
deficiency in medical services would be presumed.
notice some of the decisions in this behalf.
Savita Garg v. The Director, National Heart Institute [2004 (8) SCALE 694 :
(2004) 8 SCC 56], this Court opined:
is the common experience that when a patient goes to a private clinic, he goes
by the reputation of the clinic and with the hope that proper care will be
taken by the Hospital authorities. It is not possible for the patient to know
that which doctor will treat him. When a patient is admitted to a private
clinic/ hospital it is hospital/ clinic which engages the doctors for
treatment. ...They charge fee for the services rendered by them and they are
supposed to bestow the best care."
INDIVIDUAL LIABILITY OF THE DOCTORS There cannot be, however, by any doubt or
dispute that for establishing medical negligence or deficiency in service, the
courts would determine the following:
guarantee is given by any doctor or surgeon that the patient would be cured.
The doctor, however, must undertake a fair, reasonable and competent degree of
skill, which may not be the highest skill.
Adoption of one of the modes of treatment, if there are many, and treating the
patient with due care and caution would not constitute any negligence.
Failure to act in accordance with the standard, reasonable, competent medical
means at the time would not constitute a negligence. However, a medical
practitioner must exercise the reasonable degree of care and skill and
knowledge which he possesses. Failure to use due skill in diagnosis with the result
that wrong treatment is given would be negligence.
(v) In a
complicated case, the court would be slow in contributing negligence on the
part of the doctor, if he is performing his duties to be best of his ability.
in mind the aforementioned principles, the individual liability of the doctors
and hospital must be judged.
enumerate heretobelow the duty of care which ought to have been taken and the
deficiency whereof is being complained of in the criminal case 113 and the
civil case, respectively, so far as respondent Nos. 1 to 3 are concerned.
Mukherjee examined Anuradha, she had rashes all over her body and this being
the case of dermatology, he should have referred her to a dermatologist.
Instead, he prescribed "Depomedrol" for the next 3 days on his
assumption that it was a case of "vasculitis". The dosage of 120 mg
Depomedrol per day is certainly a higher dose in case of a TEN Patient or for
that matter any patient suffering from any other bypass of skin disease and the
maximum recommended usage by the drug manufacturer has also been exceeded by
Dr. Mukherjee. On 11th May, 1998, the further prescription of Depomedrol
without diagnosing the nature of the disease is a wrongful act on his part.
to general practice, long acting steroids are not advisable in any clinical
condition, as noticed hereinbefore. However, instead of prescribing to a quick
acting steroid, the prescription of a long acting steroid without foreseeing
its implications is certainly an act of negligence on his part without
exercising any care or caution. As it has been already stated by the Experts
who were cross examined and the authorities that have been submitted that the
usage of 80-120 mg is not permissible in TEN.
Furthermore, after prescribing a steroid, the effect of immunosuppression
caused due to it, ought to have been foreseen. The effect of immunosuppression
caused due to the use of steroids has affected the immunity of the patient and
Dr. Mukherjee has failed to take note of the said consequences.
taking over the treatment of the patient and detecting TEN, Dr. Halder ought to
have necessarily verified the previous prescription that has been given to the
patient. On 12th May, 1998 although `depomedrol' was stopped, Dr. Halder did
not take any remedial measures against the excessive amount of `depomedrol'
that was already stuck in the patient's body and added more fuel to the fire by
prescribing a quick acting steroid `Prednisolone' at 40mg three times daily,
which is an excessive dose, considering the fact that a huge amount of
"Depomedrol" has been already accumulated in the body.
saving `supportive therapy' including IV fluids/ electrolyte replacement,
dressing of skin wounds and close monitoring of infection is mandatory for proper
care of TEN patients. Skin(wound) swap and blood tests also ought to be
performed regularly to detect the degree of infection.
from using the steroids, aggressive supportive therapy that is considered to be
rudimentary for TEN patients was not provided by Dr. 115 Halder. Further
`vital-signs' of a patient such as temperature, pulse, intake- output and blood
pressure were not monitored. All these factors are considered to be the very
basic necessary amenities to be provided to any patient, who is critically ill.
The failure of Dr. Halder to ensure that these factors are monitored regularly
is certainly an act of negligence.
dressing were carried as a result of which the infection had been increased. Dr
Halder's prescription was against the Canadian treatment protocol reference to
which we have already made herein before.
It is the
duty of the doctors to prevent further spreading of infections.
is to be done is the doctors concern. Hospitals or nursing homes where a
patient is taken for better treatment should not be a place for getting
coming to know that the patient is suffering from TEN, Dr. Abani Roy Chowdhury
ought to have ensured that supportive therapy had been given. He had treated
the patient along with Dr. Halder and failed to provide any supportive therapy
or advise for providing IV fluids or other supplements that is a necessity for
the patient who was critically ill.
regards, individual liability of the respondent Nos 4, 5 and 6 is concerned, we
may notice the same hereunder.
regards AMRI, it may be noticed:
parameters of Anuradha were not examined between 11.05.1998 to 16.05.1998 (Body
Temperature, Respiration Rate, pulse, BP and urine input and output) (ii)I.V.
Fuid not administered. (I.V. fluid administration is absolutely necessary in
the first 48 hours of treating TEN) As regards, Dr. Balaram Prasad, Respondent
No. 5, it may be noticed:
Doctors refrain from using steroids at the later stage of the disease - due to
the fear of Sepsis, yet he added more steroids in the form of quick - acting
"Prednisolone" at 40g three times a day.
stood as second fiddle to the treatment and failed to apply his own mind.
doctor has the right to use the drug beyond the maximum recommended dose.
far as the judgment of the Commission is concerned, it was clearly wrong in
opining that there was no negligence on the part of the hospital or the
doctors. We are, however, of the opinion, keeping in view the fact that Dr.
Kaushik Nandy has done whatever was possible to be done and his line of
treatment meets with the treatment protocol of one of the experts, viz.
Jean Claude Roujeau although there may be otherwise difference of opinion, that
he cannot be held to be guilty of negligence.
CONCLUSION We remit the case back to the Commission only for the purpose of
determination of quantum of compensation.
principles of determining compensation are well-known. We may place on record a
few of them.
Insurance Company Limited v. Jashuben and Others [(2008) 4 SCC 162], this Court
We, therefore, are of the opinion that what would have been the income of the
deceased on the date of retirement was not a relevant factor in the light of
peculiar facts of this case and, thus, the approach of the Tribunal and the
High Court must be held to be incorrect. It is impermissible in law to take
into consideration the effect of revision in scale of pay w.e.f. 1.1.1997 or
what would have been the scale of pay in 2002.
loss of dependency, in our opinion, should be calculated on the basis as if the
basic pay of the deceased been Rs. 3295/- X 2 = Rs. 6,590/-, thereto should be
added 18.5% dearness allowance which comes to Rs. 1219/-, child education
allowance for two children @ Rs. 240/- X 2 = Rs. 480 and child bus fair Rs. 160
X 2 = Rs. 320/- should have been added which comes to Rs. 8,609/-.
the aforementioned figure 1/3rd should be deducted. After deduction, the amount
of income comes to Rs. 5,738/- per month [Rs. 8609/- - Rs. 2871/-] and the
amount of compensation should be determined by adopting the multiplier of 13,
which comes to Rs. 8,95,128/-
the present case, the High Court itself has applied the multiplier of 13. We are
of the opinion that no interference therewith is warranted. We furthermore do
not intend to interfere with the rate of interest in the facts and circumstance
of the case."
grant of compensation involving an accident is within the realm of law of
torts. It is based on the principle of restitution in integrum. The said
principle provides that a person entitled to damages should, as nearly as
possible, get that sum of money which would put him in the same position as he
would have been if he had not sustained the wrong.
Livingstone v. Rawyards Coal Co. [ (1880) 5 AC 25 ].
a death occurs the loss accruing to the dependent must be taken into account;
the balance of loss and gain to him must be ascertained ; the position of each
dependent in each case may have to be considered separately [ See Davis v.
Powell Duffrya Associated Collieries Ltd.
AC 601 ]. The said principle has been applied by this Court in Gobald Motor
Service Ltd., Allahabad v. R.M.K. Veluswami, [AIR 1962 SC 1 ].
wife to a husband may always be truly compensated by way of mandatory
compensation. How one would do it has been baffling the court for a long time.
For compensating a husband for loss of his wife, therefore, courts consider the
loss of income to the family. It may not be difficult to do when she had been
earning. Even otherwise a wife's contribution to the family in terms of money
can always be worked out. Every housewife makes contribution to his family. It
is capable of being measured on monetary terms although emotional aspect of it
cannot be. It depends upon her educational qualification, her own upbringing,
status, husband's income, etc.
Court, we may notice, has laid down certain norms for grant of compensation for
the death of members of family including the loss of child 120 in some of its
decisions. [See Lata Wadhwa v. State of Bihar (2001) 8 SCC 197 and R.K. Malik
and Anr. v. Kiran Pal & Ors. 2009 (8) SCALE 451] In R.D. Hattangadi v. Pest
Control (India) (P) Ltd. [AIR 1995 SC 755], this Court observed:
speaking while fixing an amount of compensation payable to a victim of an
accident, the damages have to be assessed separately as pecuniary damages and
damages are those which the victim has actually incurred and which are capable
of being calculated in terms of money; whereas non- pecuniary damages are those
which are incapable of being assessed by arithmetical calculations. In order to
appreciate two concepts pecuniary damages may include expenses incurred by the
claimant: (i) medical attendance; (ii) loss of earning of profit up to the date
of trial; (iii) other material loss. So far non-pecuniary damages are
concerned, they may include (i) damages for mental and physical shock, pain and
suffering, already suffered or likely to be suffered in future;
damages to compensate for the loss of amenities of life which may include a
variety of matters i.e. on account of injury the claimant may not be able to
walk, run or sit; (iii) damages for the loss of expectation of life, i.e., on
account of injury the normal longevity of the person concerned is shortened;
(iv) inconvenience, hardship, discomfort, disappointment, frustration and
mental stress in life."
Commission must, therefore, while arriving at the adequate compensation bear in
mind all these relevant facts and circumstances.
ASSESSING CRIMINAL CULPABILITY UNDER SECTION 304-A E.1. CRIMINAL NEGLIGENCE
UNDER SECTION 304-A Criminal Medical Negligence is governed by Section 304A of
the Indian Penal Code. Section 304-A of the Indian Penal Code reads as under:-
"304-A. Causing death by negligence.- Whoever causes the death of any
person by doing any rash or negligent act not amounting to culpable homicide,
shall be punished with imprisonment of either description for a term which may
extend to two years, or with fine, or with both."
ingredients of Section 304-A areas under:- (i) Death of a person (ii) Death was
caused by accused during any rash or negligence act.
does not amount to culpable homicide.
prove negligence under Criminal Law, the prosecution must prove:
The existence of duty.
breach of the duty causing death.
breach of the duty must be characterized as gross negligence.
v. Prentice and R v. Adomako:  4 All ER 935] The question in the instant
case would be whether the Respondents are guilty of criminal negligence.
Criminal negligence is the failure to exercise duty with reasonable and proper
care and employing precautions guarding against injury to the public generally
or to any individual in particular.
however, well settled that so far as the negligence alleged to have been caused
by medical practitioner is concerned, to constitute negligence, simple lack of
care or an error of judgment is not sufficient. Negligence must be of a gross
or a very high degree to amount to Criminal Negligence.
science is a complex science. Before an inference of medical negligence is
drawn, the court must hold not only existence of negligence but also omission
or commission on his part upon going into the depth of the working of the
professional as also the nature of the job. The cause of death should be direct
or proximate. A distinction must be borne in mind between civil action and the
jurisprudential concept of negligence differs in civil and criminal law. What
may be negligence in civil law may not necessarily be negligence in criminal
law. For negligence to amount to an offence the element of mens rea must be
shown to exist. For an act to amount to criminal negligence, the degree of
negligence should be much high degree. A negligence which is not of such a high
degree may provide a ground for action in civil law but cannot form the basis
for prosecution. To prosecute a medical professional for negligence under
criminal law it must be shown that the accused did something or failed to do
something which in the given facts and circumstances no medical professional in
his ordinary senses and prudence would have done or failed to do.
OF BLAME It is also of some great significance that both in the criminal as
also the civil cases, the concerned doctors took recourse to the blame game.
Some of them tried to shirk their individual responsibilities. We may in this
behalf notice the following:
response to the notice of Dr. Kunal, Dr. Mukherjee says that Depomedrol had not
been administered at all. When confronted 124 with his prescription, he
suggested that the reply was not prepared on his instructions, but on the
instruction of AMRI.
Mukherjee, thus, sought to disown his prescription at the first instance. So
far as his prescription dated 11th May, 1998 is concerned, according to him,
because he left Calcutta for attending an international conference, the
prescription issued by him became non-operative and, thus, he sought to shift
the blame on Dr. Halder.
Mukherjee and Dr. Halder have shifted the blame to Dr. Prasad and other
doctors. Whereas Dr. Prasad counter-charged the senior doctors including the
respondent No. 2 stating:
B.N. Halder (Respondent No. 2) was so much attached with the day to day
treatment of patient Anuradha that he never found any deficiency in overall
management at AMRI so much so that he had himself given a certificate that her
condition was very much fit enough to travel to Mumbai..."
to a question as to whether Dr. Halder had given specific direction to him for
control of day to day medicine to Anuradha, he stated:
was done under the guidance of Dr. Sukumar Mukherjee (Respondent No. 1), Dr.
B.N. Halder (Respondent No. 2) and Dr. Abani Roychowdhury (Respondent No.
furthermore stated that those three senior doctors primarily decided the
treatment regimen for Anuradha at AMRI.
Kaushik Nandy had also stated that three senior doctors were incharge of
states that the drugs had been administered and nursing care had been given as
per the directions of the doctors.
Respondent Nos. 5 and 6, therefore, did not own any individual responsibility
on themselves although they were independent Physicians with Post Graduate
`Errors, Medicine and the Law', Cambridge University Press, p.14., the authors,
Alan Merry and Alexander McCall Smith, 2001 ed., stated:
incidents involve a contribution from more than one person, and this case is an
illustrates the tendency to blame the last identifiable element in the claim of
causation - the person holding the `smoking gun'. A more comprehensive approach
would identify the relative contributions of the other failures in the system,
including failures in the conduct of other individuals..."
In R v.
Yogasa Karan  1 NZLR 399, the New Zealand Court opined that the hospital
is in a better position to disclose what care was taken 126 or what medicine
was administered to the patient. It is the duty of the hospital to satisfy that
there was no lack of care or diligence. The hospitals are institutions, people
expect better and efficient service, if the hospital fails to discharge their
duties through their doctors, being employed on job basis or employed on
contract basis, it is the hospital which has to justify and not impleading a particular
doctor will not absolve the hospital of its responsibilities. [See also Errors,
Medicine and the Law, Alan Merry and Alexander McCall Smith, 2001 ed.,
Cambridge University Press, p.12] It is generally expected that very senior
doctors would behave responsibly, and they were entitled to take any defence
which is available to them but they should not resort to mudslinging. This
being a case where both sides being doctors, fair dealings were expected from
EFFECT OF NEGLIGENCE A patient would feel the deficiency in service having
regard to the cumulative effect of negligence of all concerned. Negligence on
the part of each of the treating doctors as also the hospital may have been
contributing factors to the ultimate death of the patient. But, then in a case
of this nature, the court must deal with the consequences the patient faced
keeping in view the cumulative effect.
the instant case, negligent action has been noticed with respect to more than
one respondent. A cumulative incidence, therefore, has led to the death of the
patient. It is to be noted that doctrine of cumulative effect is not available
in criminal law. The complexities involved in the instant case as also
differing nature of negligence exercised by various actors, make it very
difficult to distil individual extent of negligence with respect to each of the
respondent. In such a scenario finding of medical negligence under section
304-A cannot be objectively determined.
CONCLUSION . In view of our discussions made hereinbefore, we are of the
opinion that for the death of Anuradha although Dr. Mukherjee, Dr. Halder, Dr.
Abani Roy Chowdhury, AMRI, Dr. B. Prasad were negligent, the extent thereof and
keeping in view our observations made hereinbefore, it cannot be said that they
should be held guilty for commission of an offence under Section 304-A of the
Indian Penal Code. We furthermore in a case of this nature do not intend to
exercise our discretionary jurisdiction under Article 136 of the Constitution
of India having regard to the fact that a judgment of acquittal has been
recorded by the Calcutta High Court.
OBSERVATIONS OF THE CALCUTTA HIGH COURT 128 We must express our agony in
placing on record that the Calcutta High Court in its judgment has made certain
observations which apart from being not borne out from the records, are also
otherwise highly undesirable.
the conclusions arrived at by the High Court are not based on the findings
emerging from the records. These conclusions are as produced as under:
24.5.1998, it was noted "wounds were healing well, epidermal islands have
appeared over palms, soles and trunk .............. no obvious Pseudomonas
Colony like before". All these noting in the record of Breach Candy
Hospital indicate that her skin had started healing and undoubtedly, such
healing was outcome of effective treatment.
betterment of skin lesion in the instant case could have been due to timely and
effective treatment, undoubtedly with steroids. This may indicate the benefit
of treatment at Calcutta...
In this connection it is also to be mentioned that the death certificate alone
cannot rule out the possibility of accidental suicidal or homicidal cause of
the death. A post-mortem examination alone could rule out the possibility of
these three kinds of death....On the other hand, the improvement of Anuradha as
noticed before 25.5.1998 indirectly supports the argument that the treatment at
Calcutta was at best not wrongly directed."
in the present case, it indicates that there was no fixed treatment, and no
faith was reposed on any of the accused doctors and over- jealousness of the
patient party practically brought the untimely death of a young lady.
Court observed that Anuradha died because of interference of Kunal. Such an
observation was made on the basis of some representations although his name did
not appear in the records of AMRI. It was stated:
At the close, it is to be pointed out that Dr. Kunal Saha did not repose faith
on any institution as can be ascertained from his conduct discussed hereinabove
in details. He also failed to take the investigating agency of this country
into confidence and in paragraph 25 of the complaint, it was noted --"that
the accused persons are highly influential and are likely to interfere with
investigation and as such, complainant would be left with no other alternative
than to institute the complaint before the highest magistracy of the Sessions
Division of 24-Paraganas (South)". It is rightly contended by the learned
counsel appearing on behalf of the accused doctors that such an action may lead
to two conclusions :-- (i) The complainant has no confidence on the police
investigation of this country, or, (ii) The police investigation could unveil
some untold facts or circumstances leading to the untimely death of Anuradha.
that as it may, by filing a complaint for the purpose of proving the rash and
negligent act against the three specialized doctors, the complainant party
intentionally took upon themselves a heavy burden of proving the case which
they actually failed to discharge. So it was claimed to be an uneven battle,
which was declared by the complainant party without being aware of the law on
the subject and the consequences. It is needless to mention that now-a- days
there is an attempt amongst the patient party to lodge complaint against the
attending doctors for the purpose of their punishment. On several occasions
patient party also ransacked the hospitals or chambers of the doctors and
mishandled them on the plea of negligence to duty. In this way the doctors have
been suffering from fear psychosis."
also express our great dissatisfaction when the Calcutta High Court stated:
But it is sufficiently clear that a man of the medical field now residing at
United States with family after acquiring citizenship of that country has
challenged the conduct and integrity of the three Professors. In this
connection, I deem it proper to quote a remark of Lord Denning MR in White
House v. Jordan (supra);
Take heed of what has happened in the United States. 'Medical malpractice'
cases there are very worrying, especially as they are tried by juries who have
sympathy for the patient and none for the doctor who is insured. The damages
are colossal. The doctors insure but the premiums become very high ; and these
have to be passed on in fees to the patients. Experienced practitioners 131 are
none to have refused to treat patients for fear of being accused of negligence.
Young men are even deterred from entering the profession because of the risks
involved. In the interests of all, we must avoid such consequences in England.
Not only must we avoid excessive damages. We must say and say firmly, that in a
professional man, an error of judgment is not negligent ..............".
the statement made by the High Court that the transfer certificate was forged
by the patient party is absolutely erroneous, as Dr. Anil Kumar Gupta deposed
before the trial court that he saw the transfer certificate at AMRI's office
and the words "for better treatment" were written by Dr.Balaram
Prasad in his presence and these words were written by Dr.Prasad, who told it
would be easier for them to transport the patient.
In a case
of this nature, Kunal would have expected sympathy and not a spate of
irresponsible accusation from the High Court.
SUMMARY For the reasons aforementioned, the criminal appeals are dismissed.
regards the civil appeal, the matter is remitted to the National Commission for
determining the compensation with a request to dispose of the matter as
expeditiously as possible and preferably within a period of six 132 months from
the date of receipt of a copy of this judgment. Civil Appeal is disposed of
keeping in view the stand taken and conduct of AMRI and Dr. Mukherjee, direct
that costs of Rs. 5,00,000/- and Rs. 1,00,000/- would payable by AMRI and Dr.
further direct that if any foreign experts are to be examined it shall be done
only through video conferencing and at the cost of respondents.
...............................J. [S.B. Sinha]
................................J. [Deepak Verma]
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