Mrs. Kalyani Rajan vs Indraprastha Apollo Hospital and Ors: Redefining the scope of Res Ipsa Loquitur: A Clinical Negligence Case Review

By Serena MacMillan on Nov 24 2024 8:15am

Introduction

The recent case of Mrs. Kalyani Rajan vs Indraprastha Apollo Hospital and Ors [1] is a landmark judgement by the Supreme Court, setting out an important precedent regarding the utility of the Principles of Res Ipsa Loquitur in proving clinical negligence. Moreover, the judgment revisited the issue of how the ‘average professional’ should be defined when analysing cases of potential clinical negligence.

Facts

The complainant, Appellant, Mrs. K. Rajan, filed a complaint against Respondents: Indraprastha Apollo Hospital and Dr. R. Bhatia, due to post-operative negligence which she claimed led to the death of her Husband, Mr S. Rajan.

Mr S. Rajan suffered from Type II Chari Malformations with Hydrocephalous, Chiari Malformation occurs when the cerebellum partially falls through the opening in the skull where it joins the spinal canal. [2] On the 21st of October 1998 Mr S. Rajan consulted with Dr Bhatia, a Senior Consultant in the Department of Neurosurgery, at the Indraprastha Apollo Hospital.

Dr Bhatia advised surgery. The surgery took place on the 29th of October 1998 and Mr Rajan was moved to a post-operative private room at 4:30pm. During this time he was complaining of neck pain. By 6:30pm, Mr Rajan claimed that the pain in his neck was increasing in severity. At this point, he pain was occurring alongside spells of sweating. Mr Rajan was given an injection for the pain he was experiencing in his neck, however nothing was prescribed for the sweating. Mr Rajan went into respiratory cardiac arrest at around 11:00pm that same evening and was declared brain dead shortly after. Mr Rajan was then put on life support which he relied on until the 6th November 1998, when Mr Rajan’s life support was terminated with the informed consent of Mrs K. Rajan.

Arguments on behalf of the Claimant

Mrs K. Rajan filed a complaint against the Respondents under Section 2 (c)(iii) of the Consumer Protection Act, 1986 [3], alleging that the ‘service’ proved by the hospital and the doctors suffered from ‘deficiency’. [3] Mrs Rajan alleged that Mr Rajan should have been moved to the Intensive Care Unit (ICU) instead of a private room due to the extensive nature of the surgery.

Mrs Rajan also alleged that Mr Rajan was not attended to by any doctors from Dr Bhatia’s team until he suffered the fatal cardiac arrest at 11:00pm.

Arguments on behalf of the Respondents:

The Respondents alleged that the surgery on Mr Rajan’s brain had been successful and the symptoms he suffered post-operatively were not considered post-operative complications, for this reason standard procedure was followed in regard to his care. The Respondents reassured the commission that if Mr Rajan had showed signs of post-operative complications, he would have been moved into the ICU.

The Respondents argued further that Mr Rajan was attended to by three doctors on Dr Bhatia’s team during his post-operative care.

They argued that since Mr Rajan’s symptoms were not constant with common indicators of cardiac arrest and Mr Rajan did not have a previously diagnosed heart condition, they had not way to predicting that Mr Rajan would go into cardiac arrest following the surgery.

Finally, it was argued that the respiratory cardiac arrest suffered by Mr. Rajan was not a direct result of the surgery preformed by Dr Bhatia. This argument was supported by an affidavit by Professor Gulshan Kumar Ahuja.

Issues for the Commission:

• Whether there was significant evidence to prove that the actions of the Respondents leading to Mr Rajan suffering a heart attack constituted negligence.

  
  

• If the doctrine of Res Ipsa Loquitur can be applied to this case in deciding if negligence occurred.

  
  

• The main reason the commission reached this judgment was that there was a severe lack of evidence linking the surgery itself to the subsequent cardiac arrest.

Commission Judgement

The commission held that there was not significant evidence to definitely prove that the heart attack and subsequent death of Mr Rajan accounted to post-operative negligence.

It was also held that the Principles of Res Ipsa Loquitur did not apply to the circumstances of this case and therefore there was no case of medical negligence on behalf of the Respondents. The legal doctrine of Res Ipsa Locutore is applied to prove negligence when an injury occurs which could not have possibly occurred without the presence of negligence.

Issues for the Supreme Court

The Supreme Court reviewed this case on the 17th October 2023, the significant issues taken into account were:

• If the respondents had committed negligence in not providing sufficient care following the surgery, significantly, what constituted a reasonable medical professional when assessing medical negligence;

• If the Commission itself had dismissed the Complaint unlawfully;

• If Res Ipsa Loquitur could be applied to the facts of this case.

Supreme Court Judgement

It was held that since Mr Rajan showed on signs of post-operative compilations and the surgery was successful, it was standard practice to move him into a private room. However, dizziness, sweating and neck-pain did not qualify as post-operative complications.

Furthermore, the symptoms displayed by Mr Rajan were not typical symptoms of cardiac arrest, this coupled with the fact that Mr Rajan did not have previous heart complications meant that it was impossible for the Respondents to predict that he would go into cardiac arrest.

When reaching a judgement the Supreme court implemented the judgement of Jacob Mathew Vs. State of Punjab and Anr [4]. Which implemented the Bolam Test for determining liability for negligence. Under this judgement it must be held that the actions of the Respondent would have been carried out by an ordinary competent person exercising ordinary skill in that profession.

While Mrs Rajan alleged that Mr Rajan was not attended to by any doctors from Dr Bhatia’s team until he suffered the fatal cardiac arrest at 11:00pm. However medical evidence submitted by the Respondents contradicted this claim, they revealed that Mr Rajan was examined by three doctors after complaining of neck pain. One of these doctors was on call and advising on the subsequent symptoms of sweating, increased pain and dizziness, which he explained to be normal post-operative reactions. The court agreed with the argument of the Respondents.

Finally, the judgement of Martin F. D’Souza v. Mohd. Ishfaq, [5] was implemented, with the Supreme Court holding that applying the Doctrine of Res Ipsa Loquitur (the thing speaks for itself), the judgement in Martin F. States that:

'simply because a patent has not favourably responded to a treatment given by a doctor or a surgery has failed, the doctor cannot be held straightaway liable for medical negligence by applying the doctrine of res ipsa loqitur'.

Therefore, in applying this judgement, there was no negligence in the post-operative care of Mr Rajan as the hospital followed standard procedure in his care, the fact that he reacted negatively to that standard procedure is not enough to constitute negligence.

The Supreme Court dismissed this appeal on the grounds that Mrs. Rajan had failed to establish clinical negligence of the Respondents. They also found that the Commissions previous judgement was not unlawful.

Analysis

The Supreme Court set an important precedent in this case by protecting medical professionals from blame in the instances where medical treatment does yield a favourable outcome. There are risks to any medical treatment especially surgery, the courts are reflecting this within their judgment on this case, we must be careful not to hold medical professionals to unattainable standards, some outcomes cannot be foreseen or prevented. This sets the scope of negligence for medical professionals as falling below the ‘standard practice’ implemented in similar cases.

This case sets a new standard for what is expected in regards to patient medical records and preventative care. If Mr Rajan’s previous medical records had included a history of heart disease, or previous cardiac arrests, what level of preventative, post-operative care would have been acceptable in order to prevent falling into the scope of medical negligence?

Furthermore, this case revisits what the “average professional” is defined as, setting the precedent that it has to be accepted that the average professional makes mistakes. One can’t help but wonder if this is a dangerous precedent to set without setting out strict guidance for future cases. It could allow negligent medical practitioners to escape justice by claiming that their negligence was simply a mistake, when that mistake led to death there must clear boundaries in regards to where a mistake ends and negligence begins.

[1] Mrs. Kalyani Rajan vs Indraprastha Apollo Hospital and Ors. INSC 921, (2023)

[2] Chiari malformation type I (2021) Johns Hopkins Medicine. Available at: https://www.hopkinsmedicine.org/health/conditions-and-diseases/chiari-malformation-type-i (Accessed: 07 November 2023).

[3] The Consumer Protection Act, 1986, Section 2(c)(iii)

[4] Jacob Mathew Vs. State of Punjab and Anr 6 SCC 1, (2005)

[5] Martin F. D’Souza v. Mohd. Ishfaq 3 SCC 1, (2009)