Introduction

The case of M.a. Biviji v. Sunita And Others (2023 INSC 938) adjudicated by the Supreme Court of India on October 19, 2023, delves into the intricate dynamics of medical negligence, particularly focusing on the establishment of a causal link between alleged negligence and resultant medical complications. The appellant, Dr. M.A. Biviji, alongside Suretech Hospital and other consultants, challenged the decision of the National Consumer Disputes Redressal Commission (NCDRC) which had held them liable for medical negligence resulting in significant harm to Mrs. Sunita Parvate.

The core issues revolve around the execution of a Nasotracheal Intubation (NI) procedure performed on Mrs. Sunita, the subsequent medical complications she endured, and whether these complications can be directly attributed to the alleged negligent act.

Summary of the Judgment

The Supreme Court meticulously reviewed the NCDRC's decision which had awarded Mrs. Sunita Rs. 6,11,638 as compensation for medical negligence and an additional Rs. 50,000 for litigation expenses. The NCDRC had found that the NI procedure was performed unjustifiably, replacing a functioning Tracheostomy Tube (TT), thereby constituting negligence.

However, upon appeal, the Supreme Court overturned this decision, asserting that the NCDRC failed to establish a direct and singular causal link between the NI procedure and Mrs. Sunita's extensive medical complications, including permanent respiratory deformity and voice loss. The Court emphasized the complexity of medical cases involving multiple interventions across various healthcare providers, which inherently muddles the direct attribution of negligence.

Analysis

Precedents Cited

The judgment extensively referenced two pivotal Supreme Court decisions: Jacob Mathew v. State of Punjab (2005) 6 SCC 1 and Kusum Sharma v. Batra Hospital (2010) 3 SCC 480. These cases elucidate the framework for establishing medical negligence, emphasizing the necessity of proving duty, breach, and resultant harm with a clear causal nexus.

• Jacob Mathew v. State of Punjab: Defined medical negligence and underscored the burden of proof on the complainant to establish breach of duty and resultant injury.
• Kusum Sharma v. Batra Hospital: Reinforced the standards of care expected from medical professionals and the necessity of a direct causal link between negligence and harm.

Legal Reasoning

The Court employed a methodical approach to dissecting the NCDRC's findings:

• Breach of Duty: The only act of alleged negligence was the NI procedure replacing the TT, which the NCDRC found unjustifiable given the patient's stable breathing through TT and normal bronchoscopy results.
• Causation: The Supreme Court scrutinized the link between the NI procedure and the severe medical complications. It highlighted the multifaceted treatment Mrs. Sunita received across different hospitals and the inherent risks associated with prolonged and multiple intubations following severe trauma from a road accident.
• Responsibility Attribution: The Court noted that the judgment did not clearly identify who performed the NI procedure, isolating Dr. Rajesh Swarnakar as the responsible pulmonologist, rather than the appellants.
• Evidence and Expert Testimony: The absence of a direct causal link in expert reports and subsequent medical opinions undermined the claim that the NI procedure was the sole cause of the complications.

Impact

This judgment has significant implications for the medical and legal landscapes:

• Clarification on Causation: Reinforces the necessity of establishing a clear and direct causative link between alleged negligence and resultant harm, especially in complex medical scenarios.
• Burden of Proof: Upholds the principle that the onus is on the complainant to provide irrefutable evidence of negligence and causation, protecting medical practitioners from unfounded claims.
• Professional Protection: Safeguards medical professionals from accountability in situations where multiple interventions and treatments obscure direct responsibility.
• Consumer Protection Evolution: Signals a more stringent scrutiny of medical negligence claims, potentially reducing litigation based on ambiguous or insufficient evidence.

Complex Concepts Simplified

Nasotracheal Intubation (NI)

NI is a medical procedure where an endotracheal tube is inserted through the nose into the trachea to assist or control breathing. It is typically used in short-term respiratory support scenarios.

Tracheostomy Tube (TT)

TT involves creating an opening in the neck into the trachea and inserting a tube to provide long-term respiratory support. It is considered when extended ventilation is required.

Subglottic Stenosis

This condition refers to the narrowing of the airway just below the vocal cords, which can impede normal breathing and lead to significant respiratory distress.

Tracheoplasty

A surgical procedure aimed at repairing or reconstructing the trachea to restore normal airway function.

Thrombocytopenia

A medical condition characterized by an abnormally low number of platelets in the blood, which are essential for clot formation and preventing excessive bleeding.

Conclusion

The Supreme Court's decision in M.a. Biviji v. Sunita And Others underscores the judiciary's commitment to safeguarding medical professionals from disproportionate accountability in the absence of unequivocal evidence. By mandating a clear causal connection between negligence and harm, the Court ensures that medical practitioners can perform their duties without the looming threat of unfounded litigation, provided they adhere to the standard of care recognized by the medical community.

This judgment not only clarifies the standards for establishing medical negligence but also reinforces the delicate balance between patient rights and professional protection. It serves as a pivotal reference point for future cases, emphasizing the necessity for meticulous evidence in negligence claims and promoting a fair judicial process that respects the complexities inherent in medical treatment scenarios.