SC quashes IPC 304 A proceedings against anaesthetist, holds doctor cannot be held criminally liable for procedural error by staff nurse

New Delhi: Granting relief to an anaesthetist, who had been booked in an alleged post-surgery complication death case due to the medication prescribed by her over the phone to the nurse, the Supreme Court recently discharged her.

The Apex Court bench comprising Justices Pankaj Mithal and Prasanna B. Varale set aside the Kerala High Court order refusing to quash the medical negligence case against the anaesthetist, holding that an anaesthetist would not be held guilty under Section 304-A of the IPC, for post-surgery complication, which resulted due to the improper application of medicine to the patient by the staff nurse. 

According to the Apex Court, it was entirely beyond the physical control of the off-duty anaesthetist. "Legally, an anaesthetist whose duty hours have concluded cannot be held criminally liable for a subsequent procedural error committed by a staff nurse. Even if the prosecution’s case is taken at face value that the appellant suggested a painkiller over the phone, such an act constitutes standard medical advice for postoperative pain, not gross criminal recklessness. The failure of the nurse to accurately locate the epidural space might represent a deficiency in service (civil liability), but it fundamentally lacks the gross culpability or mens rea required to invoke Section 304-A IPC," the top court bench observed.

Case Background: 

The matter goes back to 2002 when a patient, who was admitted to Kannur-based Hospital for piles surgery, died after the procedure. It was alleged by the prosecution that when the patient complained of severe pain after the surgery, the appellant, the senior anaesthetist negligently instructed a nurse to administer the analgesic sensorcaine instead of personally attending to the patient. Following this, the patient collapsed and died. The post-mortem report also attributed the death to acute coronary insufficiency, noting an 80% blockage in the left coronary artery.

Following this, an FIR was lodged against the treating surgeon. Later, the appellant anaesthetist was also named in the chargesheet. However, the Kerala High Court quashed charge-sheet against all accused with liberty to the investigating agency to move for further investigation, seeking leave of the Magistrate concerned to conduct and complete further investigation.

Therefore, an expert panel of four members was constituted, which in its final report dated 10.07.2008 unanimously opined that the death occurred due to gross negligence on the part of the hospital staff and that the same could have been prevented if analgesia was ensured by proper introduction of the drug by qualified persons. Following this, another chargesheet was filed, and the appellant doctor was booked under Sections 304-A and 34 of the IPC. 

Before the Apex Court, the appellant anaesthetist defended herself by relying on the Apex Court order in the case of Jacob Mathew vs. State of Punjab, (2005) 6 SCC 1. 

It was contended that the nurse’s failure to administer the injection properly or to call the RMO on duty or any other available doctor to give the injection cannot be a reason for the appellant to face a criminal prosecution, and doing so would only constitute giving a draconian interpretation to Section 304- A.

The doctor's counsel also addressed the allegation that while conducting the postmortem test, a swelling was found by the doctor conducting the test, based on which he concluded that the injection did not enter the epidural space. It was submitted that the existence of asymptomatic coronary artery disease was known for the first time only in the postmortem report which supplements the possibility that the cause of death cannot solely be attributed to the anesthetic injection not entering the epidural space.

It was contended that even assuming the injection did not enter the epidural space where it was supposed to enter, at the worst, it becomes a case of deficiency in service only incurring a civil liability.

Observations by Supreme Court: 

After considering the arguments, the Apex Court bench found merit in the submissions of the appellant's counsel, who argued that the High Court had failed to consider the expert panel in its proper perspective.

"There is a considerable force in the submissions of Ld. Counsel Mr. Basant that expert panel clearly shows an inconsistent and contrary stand taken by nurse *** in her statements and as such these statements are devoid of any evidentiary value so as to constitute a criminal act, generally against the appellant and particularly the rash and negligent act against the appellant. It will not be out of place to state that the surgeon (accused no. 1) admitted before the expert panel that she had consulted the appellant over phone regarding the injection after which the injection was administered. Now the statements of nurse ** are giving a totally different version, as such there is absolutely no material having any evidentiary value against the appellant," noted the Court.

Referring to the report, the bench noted that the appellant completed her shift at 5:00 p.m. and left only after ensuring that the patient was stable. It also observed that when the emergency arose at 8:00 p.m., other doctors on-duty, including an on-duty anaesthesiologist, were physically available at the hospital.

"Even if it is assumed that the appellant answered an SOS call from home and advised a painkiller, relying on the on duty hospital staff to properly execute standard post-operative pain management cannot be deemed factually negligent," noted the top court bench.

"The prescribed medicine, sensorcaine, was undisputedly the correct and necessary analgesic for the situation. Any mishap occurred purely in the mechanical execution by the nurse allegedly failing to inject it properly into the epidural space which was entirely beyond the physical control of the off-duty appellant," it further observed.

The top court bench also noted that the appellant anaesthetist was completely exonerated by the consumer forums. The Forum expressly accepted that the appellant had not given any instructions to the nurse to administer the injection, noted the Supreme Court.

It also noted that the appellant's counsel also relied on Videocon Industries Ltd. (supra), and Prem Raj (supra) which firmly establishes that once an accused is exonerated on merits in civil proceedings, allowing a criminal prosecution to continue on identical allegations constitutes a gross abuse of the process of law.

Accordingly, the top court bench held that legally, an anaesthetist whose duty hours have concluded cannot be held criminally liable for a subsequent procedural error committed by a staff nurse.

Referring to the judgment in the case of Jacob Mathew, the bench observed, "The act must be of such a nature that "no medical professional in his ordinary senses and prudence would have done or failed to do"."

Further, the Court also noted a legal flaw in the prosecution's case, highlighting that the four-member expert medical panel constituted to review the case did not include an anaesthetist.

The top court bench also noted a legal flaw in the prosecution's case. At this outset, it observed,"The appellant has also raised a ground pointing out to a legal flaw, namely non-inclusion of the anaesthetic in the four-member expert medical panel constituted to review the case. The absence of a peer specialist renders the panel inherently incompetent to evaluate the technical nuances of epidural anaesthesia and catheter management. The panel's conclusion that the appellant was "grossly negligent" for not waiting to see the drug's effect, despite her shift ending hours prior to the emergency, was highlighted as medically absurd. The prosecution's reliance on this flawed expert report violates the protective legal safeguards laid down by the Supreme Court to prevent the harassment of medical professionals."

The Court observed that criminal liability under Section 304-A IPC necessitates a direct, proximate nexus between the negligent act and the death (causa causans).