NCDRC Sets Aside Medical Negligence Finding Against SGPGI, Holds Institute Liable Only For Deficient Documentation

Brief Facts

The complainant, Rajendra Nath Keserwani, first admitted his son to the Sanjay Gandhi Post Graduate Institute of Medical Sciences (OP No.1) in November 1992 with suspected typhoid fever. Subsequent investigations, including a bone marrow test, confirmed a diagnosis of Acute Lymphoblastic Leukemia (ALL) on 02.12.1992. Chemotherapy was commenced on 18^th December 1992. The complainant later alleged that despite the diagnosis, the child continued to remain in the general ward under a paediatrician rather than being shifted to the Immunology Department.

On 09.05.1994, the child suffered a relapse and was readmitted to the Immunology Department, where he was treated by Dr. Sonia Nityanand, Dr. Chandrashekhar, and Dr. Negi (OP Nos. 3–5). During the course of treatment, he was shifted from a private room to the isolation ward. The child developed hypotension and died on 31.05.1994. The complainant contended that two death certificates reflected different causes of death—one mentioning “septic shock” and another “leukaemia.”

Alleging deficiency in service—including improper treatment, lack of consent, inappropriate ward placement, and failure to provide complete medical records—the complainant approached the U.P. State Consumer Disputes Redressal Commission.

The State Commission allowed the complaint, held the opposite parties negligent, and awarded compensation of ₹49 lakh with interest. The opposite parties filed an appeal before the NCDRC, arguing that the findings were unsupported by evidence and based on extraneous material.

Arguments by the Parties

The complainant alleged that no valid consent was taken for the bone marrow procedure, chemotherapy, or other interventions performed on the child. He contended that despite the confirmed diagnosis of Leukemia in 1992, the child continued to be managed in the general ward under a paediatrician, rather than being shifted to the appropriate specialty department.

The complainant further argued that the two death certificates issued by the hospital reflected contradictory causes of death—one mentioning “septic shock” and the other “leukaemia.” The complainant also asserted that the hospital failed to provide complete medical records, particularly from the 1992 admission, and submitted that this withholding of documents, along with alleged improper treatment and mismanagement, amounted to clear deficiency in service on the part of the opposite parties.

The Sanjay Gandhi Post Graduate Institute of Medical Sciences (OP No.1) and the treating doctors (OP Nos. 2–5) argued that the child was suffering from a terminal form of leukemia and that no evidence had been produced to establish medical negligence. They contended that the State Commission relied on downloaded internet material, treating it as expert opinion without disclosure or authentication, thereby violating the principles of natural justice and depriving them of an opportunity to rebut it.

The Opposite Parties submitted that the diagnosis of Leukemia in 1992 was made promptly and that chemotherapy and subsequent treatment were administered strictly in accordance with accepted medical protocols. The child was treated under the Paediatrics and Immunology Departments, and clarified that a Haematology Department did not exist in SGPGI at the relevant time. The Opposite Parties further emphasized that shifting the child to the isolation ward was undertaken to ensure closer observation near the nursing station and did not amount to negligence.

Observations by the Commission

The National Consumer Disputes Redressal Commission (NCDRC) held that there was no evidence to establish medical negligence on the part of the treating doctors (OP Nos. 2–5). The Commission observed that the diagnosis of leukemia in 1992 was made promptly, and that chemotherapy and subsequent treatment were administered with due diligence. It rejected the State Commission's finding that the child was carelessly treated under a paediatrician, noting that the treatment was carried out in consultation with the Immunology Department and that the Haematology Department did not exist in SGPGI at the relevant time.

The Commission strongly criticised the State Commission for deciding the case without any expert medical opinion and for relying extensively on theoretical internet material as if it were expert evidence, even though such material had never been placed on record or disclosed to the parties. This, the Commission held, amounted to a violation of the principles of natural justice, as the appellants were deprived of any opportunity to refute the material relied upon.

While the doctors were exonerated of negligence, the Commission found the Institute (OP No.1) deficient in its administrative responsibilities. It noted that SGPGI failed to maintain and furnish complete medical records—particularly from the 1992 admission—and that the consent forms produced were improperly maintained, lacking signatures and essential disclosures. Such lapses, it held, constituted clear deficiency in service.

Accordingly, the NCDRC partly allowed the appeal, setting aside the State Commission's findings of medical negligence against the doctors while holding SGPGI (O.P No.1) liable solely for deficient record-keeping. The SGPGI (O.P No.1) was directed to pay ₹5 lakh as compensation and ₹1 lakh as litigation cost.

Case Title: Sanjay Gandhi Post Graduate Institute of Medical Sciences vs Rajendra Nath Keserwani FIRST APPEAL NO.456 OF 2023

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