Holding

Transfusion of mismatched blood constitutes a clear instance of medical negligence, establishing causation and liability, and the lower tribunals' award of compensation is affirmed.

Summary

The Supreme Court examined a complaint under the Consumer Protection Act, 1986 alleging that PGI, Chandigarh and its staff negligently transfused mismatched blood to a burn‑patient, leading to her death. The patient had 50% burns, improved after initial treatment, but after receiving B+ blood instead of her A+ group on two occasions, she became severely anemic and her kidney and liver functions deteriorated, eventually dying. The Court held that transfusing incompatible blood is a clear breach of the standard of care expected of a reasonable medical practitioner and that causation could be inferred even without scientific proof. It affirmed the findings of the State and National Consumer Disputes Redressal Commissions that the hospital’s breach materially contributed to the death and that compensation was payable. Consequently, the appeal by PGI was dismissed.

Issues considered

The hospital and its medical staff were negligent in transfusing mismatched blood under the Consumer Protection Act, 1986.
Whether the mismatched blood transfusion can be causally linked to the patient’s death without definitive scientific evidence.
The appropriate standard of care for medical professionals in negligence cases – ordinary skill versus highest expertise.
The burden of proof in medical negligence actions under the Consumer Protection Act.

Legislation cited

Consumer Protection Act, 1986s. 21

Subjects

medical negligenceblood transfusioncausationConsumer Protection Actprofessional negligencestandard of careliabilitycompensation

Judgment

[2009] 9 S.C.R. 889

P.G. INSTITUTE OF MEDICAL EDUCATION & RESEARCH A
CHANDIGARH
v.
JASPAL SINGH & ORS.
(Civil Appeal No. 7950 of 2002)
8,
MAY 29, 2009
(D.K. JAIN AND R.M. LODHA, JJ.]

Consumer Protection Act, 1986 - Medical negligence -
Patient with 50% bum injuries - Transfusion of mismatched c
blood at hospital - Deterioration of condition, leading to death
- Complaint alleging medical negligence against hospital
and its staff- Forums below holding hospital and its staff liable
to pay compensation - Interference with - Held: Not called
for - Hospital's breach of duty in mismatched blood
/
D
transfusion contributed to the death of the lady - Wrong blood
transfusion is an error which no hospital/doctor exercising
ordinary care would have made - It is not an error of
professional judgment but a sure instance of medical
.,_ negligence. E'
The question which arose for consideration in this
appeal was whether forums below were justified in
i"-
~
holding that appellant-PG! hospitai and its attending
doctor/staff were negligent in transfusing wrong blood
group to complainant's wife which resulted in her death. F

Dismissing the appeal, the Court

HELD: 1.1. In civil law, the term negligence is used
for the purpose of fastening the defendant with liability
G
of the amount of damages. To fasten liability in criminal '

law, the degree of negligence has to be higher than that
of negligence enough to fasten liability for damages in
civil law. {Para 12] (897-C]
··~
889 H
890 SUPREME COURT REPORTS [2009] 9 S.C.R.

A 1.2. With regard to the professional negligence, a
professional may be held liable for negligence if he was
not possessed of the requisite skill which he professed
to have possessed or, he did not exercise, with
reasonable competence .in the given case the skill which
B he did possess. The standard to le applied for judging,
whether the person charged has been negligent or not;
would be that of an ordinary person exercising skill in that
profession. It is not necessary for every professional to
possess the highest level of expertise in that branch
c which he practices. [Para 15] [897-G-H; 898-A-B]
1.3. In the medical negligence actions, the burden is
on the claimant to prove breach of duty, injury and
causation. The injury must be sufficiently proximate to
the medical practitioner's breach of duty. In the absence
D of evidence to the contrary adduced by the opposite
party, an inference of causation may be drawn even
though positive or scientific proof is lacking. [Para 20]
[899-C-D]

E 1.4. The patient got burn injuries to the extent of 50%
on March 30, 1996. She was initially treated at an Hospital
in Ludhiana for about 20 days. Her condition improved
satisfactorily. She wa~ admitted to PGI, Chandigarh on
April 19, 1996. The available material placed before the
F State Commission shows that at the time of her
admission, she was taking medicine orally and passing
urine; 75% of eschar was removed by May 1, 1996. Her
condition had substantially improved at PGI before May
20, 1996 and she had no signs of septicemia. It was only
G after mismatched blood transfusion B+ on two
consecutive days, that she became anemic (her +-
hemoglobin level was reduced to 5 per gram) and her
kidney. and liver were deranged. It is true that her
hemoglobin was brought up in few days but her
condition otherwise got deteriorated. Although she
H
P.G. INSTITUTE OF MEDICAL EDUCATION & RESEARCH 891
CHANDIGARH v. JASPAL SINGH

survived for about 40 days after mismatched blood A
transfusion but from that it cannot be said that there was
no causal link between the mismatched transfusion of
blood and her death. Wrong blood transfusion is an error
which no hospital/doctor exercising ordinary care would
have made. Such an error is not an error of professional B
judgment but in the very nature of things a sure instance
of medical negligence. The hospital's breach of duty in
" mismatched blood transfusion contributed to her death,
if not wholly, but surely materially. Mismatched blood
transfusion to a patient having sustained 50% burns by c
itself speaks of negligence. Therefore, in the facts and
circumstances of the case, it cannot be said that the death
of wife of complainant no. 1 was not caused by the
breach of duty on the part of the hospital and its
attending staff. The view of the National Commission is
D
concurred with with as it does not suffer from any error
of law.[Paras 22 and 25] [899-G-H; 900-A-E; 901-E]

Jacob Mathew v. State of Punjab and Anr. 2005 (6) SCC
_1; Martin F D' Souza v. Mohd. lshfaq 2009 (3) SCC 1; Syed
Akbar v_ State of Karnataka 1980 (1) SCC 30; Bhalchandra E
Waman Pathe v. State of Maharashtra 1968 ACJ 38, referred
to.

Grill vs. General Iron Screw Collier Co. (1866) LR. 1 C.P.
600; Thomas v. Quatermaine 1887 (18) Q.B.D. 685; F
Donoghue v. Stevenson (1932)A.C. 562; Bo/am v_ Friern
Hospital Management Committee (1957) 2 All ER 118(QBD);
Hucks v. Cole (1968) 118 New LJ 469; Hunter v. Hanley
1955 SLT 213, referred to.

~
'On Professional Negligence : Jackson & Powell Fifth G
edition; The Physiological Basis of Medical Practice by.
Charles H. Best and Norman B. Taylor Eight Edition' Chapter
26, referred to.

H
892 SUPREME COURT REPORTS [2009] 9 S.C.R.

...
A Case Law Reference:
2oos (6) sec 1 Referred to. Para 7, 11, 16
2009 (3) sec 1 Referred to. Para 7, 16
-·
(1866) L.R. 1 C.P. 600 Referred to. Para 8 ·--
B
1887 (18) Q.B.D. 685 Referred to. Para 9

(1932) A.C. 562 Referred to. Para 10 i

1980 (1) sec 30 Referred to. Para 13
c f-
1968 ACJ 38 Referred to. Para 14
t
>--
(1957) 2 All ER 118(QBD) Referred to. Para 16
~
(1968) 118 New LJ 469 Referred to. Para 17 f-

D 1955 SLT 213 Referred to. Para 18 •...
CIVIL APPELLATE JURISDICTION : Civil Appeal No.
7950 of 2002. •'

From the Judgment & Order dated 29.09.2000 of the
E
National Consumer Disputes Redressal Commission, New
Delhi in First Appeal No. 56 of 2000: 1

Yashraj Singh Deora and T.S. Sabarish (for K.L. Mehta &
Co.) for the Appellants. '-
F
Rajat Sharma, Dinesh Verma and A.P. Mohanty for the
Respondents.

The Judgment of the Court was delivered by ·

G R.M. LODHA, J. 1. In this appeal by special leave, the
._
appellant, Post Graduate Institute of Medical Education and
Research, Chandigarh (for short, 'PGI' ) has challenged the
order dated September 29, 2000 passed by the National
Consumer Disputes Redressal Commission (for short,
H
P.G. INSTITUTE OF MEDICAL EDUCATION & RESEARCH 893
CHANDIGARH v. JASPAL SINGH [RM. LODHA, J.]

"National Commission"). By its order, the National Commission A
dismissed the appeal filed by PGI under Section 21 of the
Consumer Protection Act, 1986 (for short, 'Act, 1986' ) and
affirmed the order passed by the State Consumer Disputes
Redressat Commission, Chandigarh (for short, 'State
Commission' ) whereby it directed the PGI to pay compensation B
in the sum of rupees two lacs to the respondents 1 and 2 herein
(for short, 'the complainants') and cost of Rs. 5,000/-.

2. The brief facts of the case are thus:

On March 30, 1996, Smt. Harjit Kaur (wife of complainant C
No. 1 and mother of complainant No. 2) received accidental
burns while making tea on the stove. She sustained 50% TBSA
Ill burns involving both upper limbs, part of trunk and most of
both tower limbs. Smt. Harjit Kaur was taken to Daya Nand
Medical College and Hospital, Ludhiana immediately where D i

she responded to the treatment well. She remained admitted
in Daya Nand Medical College and Hospital 1upto April 19,
1996. Since the treatment at Daya Nand Medical College and
Hospital was expensive, the complainant No. 1 decided to shift
his wife to PGI for further treatment. On April 19, 1996, Smt. E
Harjit Kaur was admitted in PG~. Chandigarh. Dr. Varun
Kulshrestha, Senior Resident Doctor, Department of Plastic
Surgery attended to her. The condition of Smt. Harjit Kaur
started improving at PGI. On May 15, 1995, she was transfused
A+ blood which was her blood group. On May 20, 1996, the F
patient was transfused B+ blood group in the afternoon
although her blood group was A+. On the night of May 20, 1996,
the urine of the patient was reddish like blood and the attendant
nurse was informed accordingly. As to the bad luck of Smt.
Harjit Kaur, on the next day, i.e., May 21, 1996 again one bottle G
~ of B+ blood group was transfused although her blood group
was A+. Because of transfusion of mismatched blood, the
condition of Smt. Harjit Kaur became serious; her hemoglobin
levels fell down to 5mg. and urea level went very high. Later on,
it transpired that due to transfl.l.iion of mismatched blood, the
H
894 SUPREME COURT REPORTS [2009] 9 S.C.R.

A kidney and liver of the patient got deranged. The complainant
No. 1 made a written complaint to the Head of the Department
of Plastic Surgery for mismatched transfusion of blood to the
patient whereupon an inquiry was conducted through senior
doctor and wrong transfusion of the blood to the patient was
B found. The condition of Smt. Harjit Kaur started deteriorating
day by day and she ultimately died on July 1, 1996. In the
,complaint before the State Commission, the complainants
alleged that the death of Smt. Harjit Kaur was caused due to i
the negligence of Dr. Varun Kulshrestha and the medical staff
c at PGI; that there was negligence in the discharge of service
by the PGI and its doctors and they claimed damages to the
tune of rupees nine lacs for the loss of life of Smt. Harjit Kaur.

3. Dr. Varun Kulshrestha filed reply to the complaint. He
principally set up the plea that although the patient was
D transfused wrong blood but it was not due to any negligence
on his part. He stat~d that due to the care exercised by him
and the other nursing staff, the patient became alright and her
hematological and biochemical parameters became almost
normal and she recovered from mismatched blood transfusion.
E It was stated in his reply that Smt. Harjit Kaur djed of septicemia
and not by mismatched blood transfusion and, ther~fore, the
complaint was liable to be dismissed.

4. Insofar as PGI is concerned, no reply to the complaint
F was filed separately but they adopted the reply filed by Dr.
Varun Kulshrestha. The parties filed their respective affidavits
and also produced before the State Commission the summary
report and the documents concerning treatment of Smt. Harjit
Kaur.
G 5. The State Commission after hearing the parties and
upon consideration· of the materials made available to it, came
to the conclusion that. there was serious deficiency and ,I
negligence on the part of PGI and its attending doctor(s)/staff
in transfusion of wrong blood group to the patient which resulted
H
. P.G. INSTITUTE OF MEDICAL EDUCATION & RESEARCH 895
CHANDIGARH v. JASPAL SINGH [RM. LODHA, J.]
J.

in death of Smt. Harjit Kaur. The State Commission in its order A
dated February 1, 2000 held that PGI was liable to pay sum of
rupees two lac to the complainants out of which 3/4th was to
be put in the fixed deposit in favour of the minor son Amandeep
Singh (complainant no. 2) and 1/4th amount to be paid to the
complainant No. 1. The State Commission also awarded the B
cost of Rs. 5000/-.

t 6. PGI challenged the order of the State Commission in
appeal before the National Commission but without any
success.
c
7. The learned counsel for PGI raised the· same
contentions before us which were raised before the National
Commission that the cause of death of Smt. Harjit Kaur was
Septicemia and not mismatched blood transfusion. He would
submit that Smt. Harjit Kaur recovered from mismatched blood D
transfusion given to her on 20th and 21st May, 1996; her
hemoglobin level was brought up and her vital organs started
functioning normal. The learned counsel would submit that Smt.
_Harjit Kaur died due to burn injuries and the other connected
reasons arising out of said injury and not due to mismatched E
blood transfusion and, therefore, no negligence can be
attributed to the hospital and the attending doctor/s. He relied
'(
upon two decisions of this Court namely (i) Jacob Mathew v.
State of Punjab and Another 1 and (ii) Martin F D'Souza v.
Mohd. Jshfaq. 2 F
8. The term negligence is often used in the sense· of
careless conduct. Way back in 1866 in Grill vs. General Iron
Screw Collier Co. 3 , Wills J. referred to negligence as" .........
the absence of such care as it was the duty of the defendant
t,o use." G

1. (2065) 6 sec 1.
2. (2009) 3 sec 1.
3. (1866) L.R. 1 C.P. 600 at 612.
H
l-

896 SUPREME COURT REPORTS [2009] 9 S.C.R.

A 9 .. Browen L.J. in Thomas v. Quatermaine4 stated, " ...
idea of negligence and dut~' are strictly correlatiye, and there
is no such thing as negligence in the abstract; negligence is
simply neglect of some care which we are bound by law to
exercise towards someQody".
B
10. In Donoghue v. Stevenson 5 , L•rd Macmillan with
regard to negligence made the following classic statement:

~'The law takes no cognizance~ of carelessness in the
abstract. It concerns itself with carelessness only where
C there is a duty to take care and where failure in that duty
has caused damage. In such circumstances carelessness
assumes the legal quality of negligence and entails the
consequences in law of negligence. The: cardinal principle ·
of liability is that the party complained,of should owe to the
D party complaining a duty to take care, and that the party
complaining. should be able to prove that he has suffered
damage in consequence of a breach of that duty."

11. In Jacob Mathew1 this Court while dealing with
E negligence as tort referred to the Law of Torts, Ratanlal and
Dhirajlal, (24th Edn., 2002 edited by Justice G.P. Singh) and
noticed thus: ·

"Negligence is the breach of a duty caused by the
omission to do something which a reasonable man, guided
F by . those considerations which ordinarily regulate the
conduct of human affairs would. do, or doing something
whiclJ a·.prudent and reasonable man would not do.
Actionable· negligence consists. in the neglect of the use
of ordinary care .or skill towards a person to whom the
G. defendant
.
owes
4
the...duty
·. . .
of observing.-ordinary
. ' .·.
care and ~-

skill, by Which· neglect
.. : ..
the plaintiff
. . . . . .
has·
·.
suffered
\ .
injury to·. his ..
. ..

person .o~ pro.perty .. :. the definition\involves three

4. (1887)18-Q . B.o. 685 at 694 ..
H 5. (1932)A.C. 562 at {)18-619.
~ P.G INSTITUTE OF MEDICAL EDUCATION & RESEARCH 897
CHANDIGARH v. JASPAL SINGH [RM. LODHA, J.]

constituents of negligence: (1) A legal duty to exercise due A
care on the part of the party complained of towards the
party complaining the farmer's conduct within the, scope
of the duty; (2) breach of the said duty; and (3)
consequential damage. Cause of action for negligence
arises only when damage occurs; for, damage is a B
necessary ingredient of this tort."

12. Insofar as civil law is concerned, the term negligence
is used for the purpose of fastening the defendant with liability
of the amount of damages. To fasten liability in criminal law, the C
degree of negligence has to be higher than that of negligence
enough to fasten liability for damages in civil law.
13. In Syed Akbar v. State of Kamataka 6 , this Court dealt
with in details the distinction between negligence in civil law and
in criminal law. It has been held that there is a marked difference D
as tc;> the effect of evidence, namely, the proof, in civil and
crim'inal proceedings. In civil proceedings, a mere
preponderance of probability is sufficient, and the defendant is
not necessarily entitled to the benefit of every reasonable doubt;
but in criminal proceedings, the persuasion of guilt must amount E
to such a moral certainty as convinces the mind of the Court,
as a reasonable man, beyond all reasonable doubt.

14. In Bhalchandra Waman Pathe v. State of
Maharashtra7 , this Court held that while negligence is an
F
omission to do something which a reasonable man, guided
upon those considerations which ordinarily regulate the conduct
of human affaifs, would do, or doing something which a prudent
and reasonable man would not do.

15. With regard to the professional negligence, it is now G
well settled that a professional may be held liable for
negligence if he was not possessed of the requisite skill which
he professed to have possessed or, he did not exercise, with
6. (1980) 1 sec 30.
7. 1968 ACJ 38.855 H
898 SUPREME COURT REPORTS [2009] 9 S.C.R.
~-

A reasonable competence in the given case the skill which he did
possess. It is equally well settled that the standard to be applied
for judging, whether the person charged has been negligent or
not; would be that of an ordinary person exercising skill in that
profession. It is not necessary for every professional to possess
8 the highest level of expertise in that branch which he practises.

16. In Jacob Mathew1 as well as Martin F D'Souza2, this
i
Court quoted with the approval the opinion of MacNair, J in
Bo/am v. Friem Hospital Management Committee 8 :
c "[W]here you get a situation which involves the use
of some special skill or competence, then the test as to
,
whether there has been negligence or not is not the test '·
of the man on the top of a Clapham omnibus, because he
has not got this special skill. The test is the standard of
D the ordinary skilled man exercising and professing to have
that special skill. A man need not pos~ess the highest
expert skill ... It is well-established law that it is sufficient
if he exercises the ordinary skill of an ordinary competent
·. man exercising that particular art."
E
·11. In Hucks v. Co/e9 , Lord Denning stated that a medical
practitioner would be liable only where his conduct fell below
that of the standards of a reasonably competent practitioner in
his field.
F 18. Lord President (Clyde) in Hunter v. Hanley10 observed
that the true test for establishing negligenc~ in diagnosis or
treatment on the part of a doctor is whether he"1as been proved
to be guilty of such failure as no doctor of ordinary skill would
be guilty of, if acting with ordinary care.
G ...
19. In their classic work, 'On Professional Neglig~nce (fifth
8. (1957) 2 All ER 118(QBD).
9. (1968) 118 New LJ 469.
10. 1955 SLT 213.
H
P.G. INSTITUTE OF MEDICAL EDUCATION & RESEARCH899
CHANDIGARH v. JASPAL SINGH [R.M. LODHA, J.]

edition)', Jackson & Powell state that mistakes made in the A
course of treatment may be purely physical; purely intellectual
or they may fall somewhere between the two. Whichever form
the mistake takes, there are t'.vo separate questions to consider
: (i) whether the defendant made a "mistake"; (ii) if so, whether
the mistake was one which a reasonably careful and skilful a
medical practitioner would not have made. The claimant must,
of course, succeed on both questions in order to establish
negligence.

20. It needs no emphasis that in the medical negligence
actions, the burden is on the claimant to prove breach of duty, C.
injury and causation. The injury must be sufficiently proximate
to the medical practitioner's breach of duty. In the absence of
evidence to the contrary adduced by the opposite party, an
inference of causation may be drawn even though positive or
scientific proof is lacking. D

21. 'The Physiological Basis of Medical Practice (Eight
Edition)' by Charles H. Best and Norman B. Taylor in Chapter
26 deals with transfusion; b1ood groups. In respect of
Incompatible transfus'ions, while dealing with its effects, it is E
stated that if blood of the. wrong (incompatible) ABO blood
group is transfused, a hemolytic transfusion reaction usually
results red cells are destroyed and there may be jaundice with
hemoglobinemia and hemoglobinuria. Chills, fever and shock
may occur. Renal insufficiency may ensue believed by some F
to be due to a reduced blood flow through the glomeruli.

22. The patient, Harjit Kaur, got burn injuries to the extent
of 50% on March 30, 1996. She was initially treated at Daya
Nand Medical College and Hospital, Ludhiana for about 20
days. Her condition improved satisfactorily at Daya Nand G
Medical College and Hospital. She was admitted .to PGI,'
Chandigarh on April 19, 1996. The available material placed
before the State Commission shows that at the time of her
admission, Smt. Harjit Kaur was taking medicine orally and
passing urine; 75% of eschar was removed by May 1, 1996. H
900 SUPREME COURT REPORTS [2009] 9 S.C.R.

A Her condition had substantially improved at PGI before May 20,
1996 and she had no signs of septicemia. It was only after
mismatched blood transfusion B+ on two consecutive days, i.e.,
2oth and 21st May, 1996, that she became anemic (her
hemoglobin level was reduced to 5 per gram) and her kidney
B and liver were deranged. It is true that her hemoglobin was
brought up in few days but her condition otherwise got
deteriorated. Although she survived for abq_ut 40 days after
mismatched blood transfusion but from that ft .cannot be said
that there was no causal link between th~\mi.smatched
c transfusion of blood and her death. Wrong blood transfusion is
an error which no hospital/doctor exercising ordinary care would
have made. Such an error is not an error of professional
judgment but in the very nature of things a sure instance of
medical negligence. The hospital's breach of duty in
mismatched blood transfusion contributed to her death, if not
0
wholly, but surely materially. Mismatched blood transfusion to
a patient having sustained 50% burns by itself speaks of
negligence. Therefore, in the facts and circumstances of the
case, it cannot be said that tbe death of Smt. Harjit Kaur was
E not caused by the breach of duty on the part of the hospital and
its attending .staff.

23. The State Commission observed:

"..... that there has been serious deficiency and
F negligence on the part of the PGI and its attending
doctor(s)/staff for transfusing wrong blood group to the
patient which caused death of the-wife of complainant No.
1. Mismatching of blood has been confirmed by the Senior
Resident in the Death Summary also (Annexure C/7). Once
the patient is brought to the PGI or any other Institute of
G
Health Care, the back-ground/History, if any, for example
that the patient was ·maltreated by the husband, does not
absolve the Hospital from its professional obligation ...... "

24. Affirming the aforesaid view of the State Commission,
H the National Commission held thus:
P.G. INSTITUTE OF MEDICAL EDUCATION & RESEARCH 901
CHANDIGARH v. JASPAL SINGH [R.M. LODHA, J.]

"..... It is seen that the patient's kidney was damaged and A
the blood level reached to 100 gms. percentage,
hemoglobin came down to 5 mg. after the mismatched
blood transfusion was given by the Doctor in the said
Hospital. It was only after the Complainant gave the written
complaint to the hospital regarding the wrong transfusion s
of blood given to the patient, an inquiry was made and it
was found correct. The damage control treatment started
only after the written complaint was given by the
complainant. Though it is argued by the Counsel for the
Appellant that the percentage levels were brought down to c
normal, it is very clear· to us that the internal imbalances
of liver and kidney functioning and deteriorating
• hemoglobin levels started only after the mismatched blood
transfusion was given. Though septicemia has been
written as the ultimate cause of death, the patient's health D
took a nose dive only after wrong blood was given to her
and this is clearly negligence on the part of the Doctors· of
the Hospital which the appellants cannot disown or absolve
themselves .... n

25. We concur with the view of the National Commission E
as it does not suffer from any error of law.

26. In the result, the appeal fails and is dismissed with
costs which we quantify at Rs. 20,000/-.
, N.J. Appeal dismissed. F