No medical negligence in doctor's Total Knee Replacement case- Consumer court relief to Medanta Medicity, Orthopaedic surgeon

New Delhi: The National Consumer Disputes Redressal Commission (NCDRC) recently dismissed a medical negligence complaint filed by a doctor against Medanta Hospital, The Medicity, Gurugram, and its orthopaedic surgeon in a Total Knee Replacement (TKR) surgery case.

The apex court upheld the Haryana State Commission's earlier order rejecting the complaint.

The Commission held that no negligence or deficiency in service was proved, noting that complications like infection are known risks in knee replacement surgeries, especially in patients with Rheumatoid Arthritis. It further observed that the complainant failed to present expert evidence to support her claims and that doctors cannot guarantee successful outcomes in every case if they have followed standard medical practices.

The Bench comprising presiding member Dr Inder Jit Singh and member Dr Sudhir Kumar Jain observed, 

"The respondent no 3 (orthopaedic surgeon) cannot be held liable for medical negligence due to mere fact that the left knee of the appellant could not get the desired relief. There is no evidence that the respondent 3 has failed to exercise the due skill possessed by him in discharging of his duties i.e. during the treatment of the appellant."

It further held, 

"The doctors must treat patients attentively and consciously. Simultaneously medical negligence should not be infer in casual manner rather it must be established with cogent, rational and convincing evidence by the person who is claiming negligence qua medical professional."

The Bench was hearing a first appeal filed by the late Dr Madhu Gupta against the Haryana State Commission’s 2017 order, which had dismissed her medical negligence complaint against Medanta and associated doctors and upheld the state commission’s verdict.

Background

The complainant and appellant in this case was a doctor (now dead) who had been suffering from arthritis for a long time and developed knee problems in 2010. She approached Medanta, The Medicity, Global Health Private Limited and was advised of knee replacement surgery by an orthopaedic surgeon of the hospital. Accordingly, she was admitted to the hospital and underwent knee replacement surgery. However, after the procedure, she experienced continuous discharge of fluid from her left knee. Due to the ongoing issue, she was re-admitted and underwent a second surgery.

Although the discharge summary listed the orthopaedic surgeon as the treating doctor, the appellant alleged that the procedures were actually carried out by junior doctors under his supervision, which she and her husband objected to. 

It was alleged that despite the second surgery, the problem persisted, and the doctors at the hospital then treated her for tuberculosis without conducting proper medical tests or confirming the diagnosis. Later, the appellant consulted doctors at Indraprastha Apollo Hospital, where she was informed that she was not suffering from tuberculosis. Instead, the doctors identified an infection in the implant and advised removal of the implant.

The patient was re-admitted to Medanta on 26.09.2011, where the infected implant was removed. The doctors, after removal of the implant, again advised implantation as the implant got infected due to unavoidable circumstances on a previous occasion. However, even after revision surgery, the discharge from her knee persisted.

Following this, she underwent a biopsy, following which the wound began bleeding. She was discharged with advice to return after a month. With no improvement and continued discharge of fluid and blood, she approached AIIMS, New Delhi, in January 2012, where grafting and VAC dressing were performed. Although the discharge stopped, she remained unable to walk properly.

The patient claimed that prior to the surgery, she was able to walk and manage her hospital, but due to her condition, she had to shut it down, leading to financial losses and ongoing medical expenses.

Alleging medical negligence and deficiency in service, she filed a consumer complaint before the Haryana State Consumer Disputes Redressal Commission, Panchkula. She sought Rs. 10 lakh (with 18% interest) towards treatment costs, Rs. 10 lakh for physical suffering, Rs. 5 lakh for mental agony, Rs. 20 lakh for loss of income and professional status, Rs. 2 lakh for litigation expenses, along with any other relief deemed appropriate.

The respondents i.e. the hospital and the treating doctors, except AIIMS, New Dellhi filed their written statements before the State Commission. The respondents, in their joint reply as recorded in the State Commission’s order, denied all allegations made by the appellant, terming them false and baseless. They maintained that the treatment provided to the appellant was in accordance with established medical standards and protocols.

They submitted that the patient's left knee was more painful than the right. She was already on medication for hypertension and Rheumatoid Arthritis. Further examination revealed severe deformity in both knees, including dislocation of both patellae (knee caps), along with a knock-knee deformity of 10 degrees in the right knee and 20 degrees in the left knee, with gross instability on side-to-side movement of both knees.

Respondent no. 5, a senior resident at the hospital, filed a separate reply, denying all allegations. He stated that he was working as an Attending Consultant in the Radiology Department at Medanta and had no role in the appellant’s surgery or treatment. He further pointed out that no specific allegations of negligence were made against him. He argued that the complaint was time-barred and lacked material particulars, and that relevant facts had been suppressed by the appellant.

It was submitted that the patients who are suffering from Rheumatoid arthritis and on medication for Rheumatoid arthritis are at an increased risk for the development of deep post-operative infection.

The State Commission, by order dated 27.01.2017, dismissed the complaint after finding no evidence of medical negligence. The Commission observed that knee replacement and re-implantation procedures carry inherent risks, including reinfection and that due care and standard treatment protocols were followed.

Aggrieved by the State Commission's judgment, the patient filed a First Appeal pleading that it was illegal, arbitrary and contrary to facts and evidence on record.

Observation

Referring to a Supreme Court ruling, the Commission observed that a mere deviation from standard professional practice does not automatically amount to negligence. It noted that an error of judgment by a medical professional cannot be considered negligence in itself. The Court further explained that doctors may sometimes choose procedures involving higher risk if they genuinely believe such options offer better chances of success compared to safer alternatives with lower success rates.

It stated, "The Supreme Court also discussed rule of res ipsa loquitur and stated that it is not of universal application and has to be applied with extreme care and caution to the cases of professional negligence and in particular that of the doctors otherwise it would be counter-productive. The doctor cannot be held liable by applying doctrine of res ipsa loquitur because a patient has not favourably responded to a treatment given by a physician or a surgery has failed."

The Commission noted that patients with Rheumatoid Arthritis, especially those on medication, are at a higher risk of infection following Total Knee Replacement (TKR). In the present case, since the appellant was suffering from Rheumatoid Arthritis and undergoing treatment, she was inherently at an increased risk of post-surgical infection. The Commission found merit in the arguments advanced by counsel for respondents no. 1 to 5 (hospital and the doctors) and agreed with their submissions.

The Apex Commission upheld the state commission's order that held that the appellant failed to produce any expert evidence, and her claim could not be accepted based solely on her statements, especially when the respondents had supported their case with medical records and literature.

Further, the Commission held that the case involved complex medical issues, including Rheumatoid Arthritis and multiple surgeries, making expert evidence necessary. Citing precedents such as Dr C.P. Sreekumar vs S. Ramanujam and Nalini vs Manipur Hospital, it reiterated that the burden to prove negligence lies on the claimant. Accordingly, it found no merit in the appellant’s argument and upheld the State Commission’s findings.

"It was for the appellant/the present appellants to establish medical negligence on the part of the respondents no 1 & 3 in particular by leading cogent and convincing evidence and mere assertions in complaint or deposition in affidavit tendered in evidence are not sufficient to establish medical negligence as observed by this Commission in Nalini V Manipur Hospital & others."

The appellant alleged negligence in her treatment and deficiency in service, but could not prove that the respondents, and in particular the hospital and the orthopaedic surgeon, were negligent in the treatment of the appellant.

Referring to Jacob Mathew vs State of Punjab, the Commission observed that a surgeon cannot guarantee a 100% successful outcome of a procedure and can only assure that they possess the requisite skill and follow accepted medical standards.

In the present case, it held that respondent no 3 (orthopedic surgeon) adhered to established practices, protocols, and procedures recognized by the medical profession.

The Commission said,

"It is not always necessary that in every case the condition of the patient would improve and the surgery is successful to the satisfaction of the patient. It is not case of the appellant that the respondent no 3 (surgeon) was not possessing requisite qualification or skill for the treatment. There is no evidence to prove that the respondent no 3 has failed to exercise due diligence, care or skill while performing surgery of the appellant on various occasions."

It further said, 

"The respondent no 3 cannot be held liable for medical negligence due to mere fact that the left knee of the appellant could not get the desired relief. There is no evidence that the respondent 3 has failed to exercise the due skill possessed by him in discharging of his duties i.e. during the treatment of the appellant. The respondent no 3 cannot be levelled with negligence as he performed his duties with reasonable skill and competence. The respondent no 3 conducted surgeries in good faith for the benefit of the patient i.e. the appellant and in accordance with recognized surgical practices and was not deviated from accepted medical standards or that the outcome was the result of any dereliction of duty by the opposite parties."

The Commission held that the appellants cannot invoke the doctrine of res ipsa loquitur in the present case. It noted that both knees underwent TKR, but complications arose only in the left knee, while the right knee remained unaffected.

It concluded that there was no deficiency in service on the part of the respondents, particularly respondents no. 1 (Medanta) and 3 (orthopedic surgeon). It also observed that no specific allegations of medical negligence were made against the other respondents. 

"The doctors must treat patients attentively and consciously. Simultaneously medical negligence should not be infer in casual manner rather it must be established with cogent, rational and convincing evidence by the person who is claiming negligence qua medical professional," the Commission said.

The Commission held that respondent no. 3 had conducted the surgery and post-operative care with due diligence and in line with accepted medical standards.

It concluded that the appellants failed to prove medical negligence or deficiency in service. Finding no infirmity in the State Commission’s well-reasoned order, and no merit in the grounds raised in the appeal, the Commission upheld the impugned order and dismissed the appeal.

To view the order, click on the link below:

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