Medical Records Prevail Over Verbal Claims; No Negligence If Procedure Done by Competent Doctor with Informed Consent: Punjab State Consumer Commission - 2025-05-05

Reliable Legal Information.

Punjab Consumer Commission Overturns Negligence Ruling, Stresses Primacy of Medical Records

Chandigarh, Punjab - The State Consumer Disputes Redressal Commission, Punjab, has overturned a District Commission order, ruling that Arzoo Hospital and its doctor were not guilty of medical negligence in a case involving an epidural injection that allegedly led to paralysis. The Commission, comprising Hon’ble Mrs. Justice Daya Chaudhary (President) and Mr. Vishav Kant Garg (Member), emphasized that clear and consistent medical records take precedence over contradictory verbal allegations.

The decision, delivered on January 16, 2025, allowed the appeal filed by Arzoo Hospital and Dr. Dev Dutt Bhakhri, while dismissing a cross-appeal from the patient's family seeking enhanced compensation.

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Background of the Dispute

The case originated from a complaint filed by Darshan Singh (since deceased), who was admitted to Arzoo Hospital in October 2017 for severe spinal pain. His family alleged that Dr. Dev Dutt Bhakhri, the second opposite party, administered an epidural injection in his spinal cord, which caused the lower part of his body to become non-functional. They claimed this amounted to wrong treatment, for which the hospital charged Rs. 45,000, and sought a refund and compensation totaling over Rs. 4.5 lakhs.

The District Consumer Commission, Ludhiana, had previously ruled in favour of the complainant, ordering the hospital to refund Rs. 1,45,000 in treatment costs and pay Rs. 2,50,000 as compensation, finding the hospital and Dr. Bhakhri negligent.

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Key Arguments in the Appeal

Arzoo Hospital's Position: The hospital contested the District Commission's findings, arguing that the treatment was administered not by Dr. Bhakhri, but by Dr. Deepak Goyal, a qualified Ortho Surgeon. They presented medical records showing that after an MRI revealed a massive lumbar disc herniation, Dr. Goyal strongly advised immediate surgery at a higher center. However, the patient's family declined due to financial constraints. The hospital contended that the epidural injection was administered by Dr. Goyal only as a pain relief measure at the family's request and after explaining all risks, including the fact that it was not a cure. They submitted a consent form signed by the patient’s son and procedure notes identifying Dr. Goyal as the performing surgeon and Dr. Bhakhri as his assistant.

Complainant's Family's Position: The complainant's counsel argued that Dr. Bhakhri, who was not a specialist, administered the injection, leading to the patient's paralysis. They pointed to alleged contradictions in the doctors' testimonies regarding who was present in the operation theatre and claimed that Dr. Goyal was not on duty when the procedure took place. They also challenged the validity of the consent, arguing it should have been taken from the conscious patient himself, not his son.

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Commission's Analysis and Legal Reasoning

The State Commission conducted a detailed review of the evidence, focusing on the medical records submitted by the hospital.

Primacy of Documentary Evidence

The Commission found that the hospital's records, including the patient registration form, nursing charts, and procedure notes, consistently named Dr. Deepak Goyal as the treating physician. Crucially, the operation notes from 5:10 PM on October 21, 2017, explicitly stated: " Surgeon : Dr. Deepak Goyal, Assistant Dutt Dev Bhakhri ".

The Commission noted, "when Dr. Deepak Goyal and Dr. Dev Dutt Bhakhri, both were present in the Operation Theatre, it was not appropriate to assume that in the presence of Specialist Doctor, other Doctor, had administered the injection upon the patient... Correct picture had been reflected only on the basis of medical record."

Informed Consent and Standard of Care

The Commission rejected the argument that the consent was invalid. It distinguished the case from precedents like Samira Kohli vs. Dr. Prabha Manchanda , noting that here, the family was fully informed about the need for surgery and the limited, palliative nature of the injection. The consent form, written in Punjabi, clearly stated that the family refused surgery and accepted the injection despite knowing it was not a permanent solution.

Citing the Supreme Court's judgment in M.A. Biviji Versus Sunita and others (2024) , the Commission reiterated that a higher threshold of proof is required to establish medical negligence. It concluded that the hospital had successfully demonstrated that its doctors followed reasonable standards of medical practice.

"In the present case, the allegations of the Complainant are only on the basis of assumptions and presumptions, whereas medical records speaks against that. Therefore, we are preferred/accepted the medical record against verbal assertions," the Commission held.

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Final Verdict and Implications

The State Commission concluded that the District Commission had erred by overlooking the substantial medical evidence that proved a competent and qualified surgeon performed the procedure after obtaining informed consent. Finding no 'medical negligence', 'deficiency in service', or 'unfair trade practice', the Commission set aside the District Commission's order and dismissed the original complaint.

This judgment serves as a significant reminder of the critical importance of maintaining thorough and accurate medical records, as they form the bedrock of defense in medical negligence litigation.