Off-duty anaesthetist not criminally liable for nurse's procedural error: Supreme Court

The Supreme Court recently closed the criminal proceedings against a senior anaesthetist accused of medical negligence after she allegedly instructed a nurse by telephone to administer an injection to a patient who later died [Supriya Kumari M.C. v State of Kerala].

In a judgment delivered on May 25, a Bench of Justices Pankaj Mithal and Prasanna B Varale found that an anaesthetist (appellant), whose duty hours had ended, could not be held criminally liable for an error allegedly committed by a nurse.

"Legally, an anaesthetist whose duty hours have concluded cannot be held criminally liable for a subsequent procedural error committed by a staff nurse," the Court said.

The Court held that the prosecution version that the anaesthetist had given such instruction itself was not proved.

It further held that even if the prosecution's case was accepted, telephonic advice to administer a painkiller amounted to standard medical advice for post-operative pain, not gross criminal recklessness.

Even if it is assumed that the appellant-accused answered an SOS call from home and advised a painkiller, relying on the duty hospital staff to properly execute standard post-operative pain management cannot be deemed factually negligent, the Court held.

The prescribed medicine, sensorcaine, was undisputedly the correct and necessary analgesic for the situation and any mishap occurred purely in the mechanical execution by the nurse allegedly failing to inject it properly into the epidural space which was entirely beyond the physical control of the off-duty appellant, the Court ruled.

"The failure of the nurse to accurately locate the epidural space might represent a deficiency in service (civil liability), but it fundamentally lacks the gross culpability or mens rea required to invoke Section 304-A IPC," the Court added.

The Court thus allowed the appeal filed by anaesthetist, Dr. Supriya Kumari, challenging Kerala High Court order refusing to close criminal proceedings initiated against her in the case.

The case arose from the death of a patient, one KP Muralidhar, who underwent piles surgery at a hospital in Kannur in May 2002. After the surgery, his condition worsened, and he later collapsed.

The post-mortem examination revealed 80% blockage in his left coronary artery and identified the cause of death as acute coronary insufficiency.

The prosecution alleged that the accused anaesthetist asked a nurse to give the patient a painkiller injection instead of administering it herself, after which the patient lost consciousness and collapsed.

Although the FIR was initially registered only against the surgeon, subsequent investigation led to the filing of charge sheets against the surgeon, the anaesthetist and the nurse under Sections 304-A (causing death by negligence) and 34 (common intention) of the Indian Penal Code (IPC).

Meanwhile, the deceased patient’s family also pursued proceedings before the District Consumer Disputes Redressal Forum, Kannur. In 2017, the Consumer Forum found that the anaesthetist had not instructed the nurse to administer the injection and held the hospital liable.

The anaesthetist's discharge plea before the trial court was rejected in 2011 and her plea challenge the same before the sessions court was dismissed in 2018.

The Kerala High Court subsequently refused to close the criminal proceedings in October 2024, following which she approached the Supreme Court.

Before the Supreme Court, Dr. Kumari relied heavily on her exoneration in the consumer proceedings.

The Supreme Court said that the consumer forum had held that the she had not instructed the nurse to administer the injection and that the deceased patient’s family had not challenged that finding before the appellate consumer forum, thereby allowing her exoneration to attain finality.

The Court further reiterated that for a criminal charge under Section 304A of the IPC to survive, the prosecution must establish gross negligence and not merely a medical error.

In this case, the accused's actions were far too remote from the ultimate cause of death.

"The post-mortem certificate conclusively established that the deceased had an asymptomatic 80% blockage in his coronary artery. The medical evidence proved that the immediate cause of death was acute
coronary insufficiency resulting in a heart attack. While the improper administration of the painkiller by the nurse might have failed to alleviate the surgical pain—which in turn induced stress that triggered the fatal cardiac event—this chain of events cannot legally be attributed to the appellant," the Court said.

It was observed that criminal medical negligence requires a significantly higher threshold, and the act must be such that no medical professional in their ordinary senses and prudence would have done or failed to do.

“Criminal liability under Section 304-A IPC necessitates a direct, proximate nexus between the negligent act and the death (causa causans). Legally, the appellant's actions were far too remote from the ultimate cause of death,” the judgment stated.

The Court also noted that the expert panel constituted to review the case did not include an anaesthetist.

"The absence of a peer specialist renders the panel inherently incompetent to evaluate the technical nuances of epidural anaesthesia and catheter management," the Court said while discharging the accused anaesthetist.

[Read Judgment]