DEEP NURSING HOME AND ANOTHERversusMANMEET SINGH MATTEWAL AND OTHERS

                 [2025] 10 S.C.R. 26 : 2025 INSC 1094

                 Deep Nursing Home and Another
                               v.
                Manmeet Singh Mattewal and Others
                       (Civil Appeal No. 4296 of 2025)
                             09 September 2025
           [Sanjay Kumar* and Satish Chandra Sharma, JJ.]


                            Issue for Consideration
       Validity of the finding that appellant no.2-doctor, the Obstetrician/
       Gynaecologist who conducted the delivery of newborn child, which
       resulted in death of both woman and newborn child, is guilty of
       medical negligence and deficiency in service.

                                   Headnotes†
       Medical Negligence – Death of a wife-C and newborn child
       of respondent no.1 – Allegation of medical negligence – The
       SCDRC found appellant no.1-Nursing home and appellant
       no.2-doctor medically negligent on the ground that they did
       not exercise due care and caution in treating C but held that
       there was no fault on their part insofar as the death of the
       newborn child was concerned – The SCDRC directed them
       to pay ₹20,26,000/- to the complainants (respondent nos.1
       and 2) – In appeal, the NCDRC came to the conclusion that
       no liability would attach to Nursing Home and pinned the
       entire responsibility of paying ₹20,26,000/- upon appellant
       no.2 – Correctness:
       Held: There are five Medical Boards/Committees’ reports –
       Significantly, all the above reports came about upon the instigation
       and at the behest of respondent no.1 himself – However, except for
       one report which, owing to lack of sufficient data, left one question
       open, i.e., the possible pre-existing conditions that may have led
       to the death of C none of the reports held appellant no.2-doctor
       negligent – Further, given the settled legal position that every
       failure in the treatment of a patient does not automatically lead
       to an assumption of medical negligence, this Court finds that the
       opinions expressed by the doctors and experts, who constituted
       these Medical Boards/Committees, clearly tilted the balance


* Author
[2025] 10 S.C.R.                                                           27

                     Deep Nursing Home and Another v.
                     Manmeet Singh Mattewal and Others

     in favour of appellant no.2-doctor, as none of them found any
     medical negligence on her part – As already noted hereinbefore,
     these bodies were constituted at the behest of respondent no.1
     himself and he cannot, therefore, fight shy of the conclusions and
     findings rendered by them – Simply because a patient did not
     favourably respond to the treatment given by a physician or if a
     surgery failed, the doctor cannot be held liable per se by applying
     the doctrine of res ipsa loquitur – The specific claim of respondent
     no.1 in complaint case was that there was medical negligence
     on the part of appellant no.2-doctor and the nursing home in the
     post-delivery treatment only – The NCDRC rendered a clear finding
     that there was no medical negligence in the handling of C’s labour,
     including her delivery; the management of the baby’s problem; and
     the post-delivery management at the nursing home – The entire
     focus of the NCDRC, however, was only upon the antenatal care
     and management of the patient and its pinpointed findings were
     also in relation to the said period and treatment only – Once his
     case, as pleaded and projected, was not made out, the NCDRC
     clearly erred in building up a new case on his behalf and in pinning
     negligence and liability upon appellant no.2-doctor in the context
     of antenatal care and management of the patient, which was
     never the subject matter of the complaint case – In doing so, the
     NCDRC overstepped its power and jurisdiction – The impugned
     order passed by the NCDRC, confirming the SCDRC’s judgment on
     the new grounds made out by it, therefore, cannot be sustained –
     Respondent no.1 directed to return and refund the sum received
     by him. [Paras 22, 23, 25, 28, 30, 31]

                              Case Law Cited
     Universal Sompo General Insurance Co. Ltd. v. Suresh Chand
     Jain and Another [2023] 10 SCR 1155 : (2024) 9 SCC 148; Jacob
     Mathew v. State of Punjab and Another [2005] Supp. 2 SCR
     307 : (2005) 6 SCC 1; Martin F. D’Souza v. Mohd. Ishfaq [2009]
     3 SCR 273 : (2009) 3 SCC 1; Devarakonda Surya Sesha Mani
     and Others v. Care Hospital, Institute of Medical Sciences and
     Others, 2022 SCC OnLine SC 1608; A.V.G.P. Chettiar & Sons and
     others v. T. Palanisamy Gounder (2002) 5 SCC 337; Venkataraman
     Krishnamurthy and Another v. Lodha Crown Buildmart (P) Ltd.
     (2024) 4 SCC 230; Rama Kt. Barman (Died) Thr. LRs. v. Mohd.
     Mahim Ali and Others [2024] 8 SCR 727 : 2024 SCC OnLine
     SC 4083; Trojan and Company v. Rm. N.N. Nagappa Chettiar
28                                                          [2025] 10 S.C.R.

                          Supreme Court Reports


      [1953] 1 SCR 789 : (1953) 1 SCC 456; Ram Sarup Gupta (Dead)
      by LRs v. Bishun Narain Inter College and Others [1987] 2 SCR
      805 : (1987) 2 SCC 555 – referred to.

                              List of Keywords
      Medical Negligence; Deficiency in service; Obstetrician/
      Gynaecologist; Assumption of medical negligence; Doctrine of
      res ipsa loquitur; Post delivery treatment; Antenatal care and
      management of the patient; Overstepping jurisdiction; Power and
      jurisdiction.

                             Case Arising From
      CIVIL APPELLATE JURISDICTION: Civil Appeal No. 1662 of 2016
      From the Judgment and Order dated 09.05.2012 of the National
      Consumers Disputes Redressal Commission, New Delhi in FA
      No. 158 of 2007

                          Appearances for Parties
      Advs. for the Appellants:
      Paramjit Singh Patwalia, Mrs. Kawaljit Kochar, Sr. Advs.,
      Deepanshu, Utkarsh Vats, Shivam Jasra, Ms. Deveshi Chand,
      Drouhn Garg, Rajivkumar.
      Adv. for the Respondents:
      Satinder Gulati, Raj Kishor Choudhary, Mohit Gupta, Ms. Meera
      Mathur, Dr. Sushil Kumar Gupta, Mrs. Sunita Gupta, Manan Verma,
      Shubham Arora, Sumit Kumar, Ms. Ipshita Gupta.

                 Judgment / Order of the Supreme Court

                                 Judgment

      Sanjay Kumar, J

      Manmeet Singh Mattewal, respondent No. 1, lost his wife, Charanpreet
      Kaur, and his newborn son within the span of a few hours. Shiraz
      Mattewal, respondent No.2, is his older son. Our sympathies aside,
      we are called upon to examine the validity of the finding that Dr. (Mrs.)
      Kanwarjit Kochhar, appellant No.2, the Obstetrician/ Gynaecologist
      who conducted the delivery is guilty of medical negligence and
[2025] 10 S.C.R.                                                      29

                         Deep Nursing Home and Another v.
                         Manmeet Singh Mattewal and Others

      deficiency in service. By judgment dated 31.01.2007 in Complaint
      Case No. 56 of 2006, the State Consumer Disputes Redressal
      Commission, Union Territory, Chandigarh1, had found her and Deep
      Nursing Home, Chandigarh, appellant No.1, medically negligent
      on the ground that they did not exercise due care and caution in
      treating Charanpreet Kaur but held that there was no fault on their
      part insofar as the death of the newborn child was concerned. The
      SCDRC directed them to pay ₹20,26,000/- to the complainants,
      Manmeet Singh Mattewal and Shiraz Mattewal. However, as they
      were covered by the insurance policy issued by New India Assurance
      Company Limited, respondent No. 3 herein, the company was directed
      to pay ₹20,00,000/- and the balance was directed to be paid by
      them. Interest @ 9 % was awarded if the amount was not paid in
      one month. Costs of ₹10,000/- were also awarded.
2.    Deep Nursing Home, Chandigarh, and Dr. Kanwarjit Kochhar filed
      First Appeal No. 158 of 2007 before the National Consumer Disputes
      Redressal Commission, New Delhi2, assailing the SCDRC’s judgment.
      First Appeal No. 193 of 2007 was filed separately by New India
      Assurance Company Limited. However, by order dated 09.05.2012,
      the NCDRC dismissed both appeals. Therein, the NCDRC came
      to the conclusion that no liability would attach to Deep Nursing
      Home, Chandigarh, and pinned the entire responsibility of paying
      ₹20,26,000/- upon Dr. Kanwarjit Kochhar. As ₹6,00,000/- had already
      been deposited pursuant to its order dated 12.04.2007 and was
      withdrawn by Manmeet Singh Mattewal, the NCDRC directed her to
      pay the balance sum of ₹14,26,000/- in 6 weeks along with costs of
      ₹14,000/-. In the passing, we may note that the NCDRC reserved
      judgment in the appeals on 27.07.2010 but the order was pronounced
      by it nearly two years later, on 09.05.2012!
3.    Despite the clean chit given to it by the NCDRC, Deep Nursing
      Home, Chandigarh, joined Dr. Kanwarjit Kochhar in filing the special
      leave petition from which the present appeal arises. By order dated
      10.02.2014, this Court directed a further sum of ₹4,00,000/- to be
      paid to Manmeet Singh Mattewal and Shiraz Mattewal, respondent
      Nos. 1 and 2 herein. Leave was granted by this Court on 15.02.2016.


1    for short, ‘the SCDRC’
2    for short, ‘the NCDRC’
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4.      At the outset we may note that, in Universal Sompo General
        Insurance Co. Ltd. vs. Suresh Chand Jain and another3, this
        Court affirmed that a special leave petition under Article 136 of the
        Constitution is not the proper remedy against an appellate order
        passed by the NCDRC. However, as this matter was entertained and
        has been pending on the file of this Court for over twelve years, we
        do not think it proper to relegate the appellants at this late stage to
        the alternative remedy under Article 226 of the Constitution before
        the jurisdictional High Court.
5.      We may now note the contents of Complaint Case No. 56 of 2006
        filed before the SCDRC: Charanpreet Kaur, a co-operative bank
        manager on deputation as a lecturer in the Punjab Institute of
        Cooperative Training, was aged about 32 years and was earning
        a monthly salary of ₹25,682/-. She was in the 8th month of her
        pregnancy when she started consulting Dr. Kanwarjit Kochhar of
        Deep Nursing Home, Chandigarh. According to the complaint case,
        she visited the nursing home several times and also underwent the
        tests prescribed from time to time. Photocopies of the ultrasound
        tests done on 08.08.2005, 11.11.2005 and 16.12.2005 were filed in
        this regard. It was stated that the couple visited the nursing home
        on 10.11.2005, 29.11.2005 and 09.12.2005 for check-ups and were
        assured that all was well and that it would be a normal delivery. A
        copy of the prescription dated 10.11.2005, with entries, was also
        filed. Charanpreet Kaur was admitted on 21.12.2005 at about 11.00
        AM for delivery. However, the newborn child died instantly after
        birth, which took place at 02.00 AM on the next day. It was alleged
        that the nursing home was ‘inadequately and ill equipped’ to handle
        emergencies during deliveries and there were no facilities available
        in that regard.
6.      According to the averments made, the mother was informed about
        the death of the newborn child which resulted in her going into shock
        and caused profuse bleeding. It was alleged that no blood was
        readily available in the nursing home for transfusion and the delay
        in shifting her to the Post Graduate Institute of Medical Education
        and Research, Chandigarh4, at 05.30 AM resulted in her being


3     (2024) 9 SCC 148
4     for short, ‘the PGI’
[2025] 10 S.C.R.                                                         31

                        Deep Nursing Home and Another v.
                        Manmeet Singh Mattewal and Others

       declared ‘brought dead’ on arrival. It was further alleged that the
       staff of Deep Nursing Home did not bring any reference papers or
       history sheet to facilitate her treatment at the PGI. The van in which
       she was taken was also ill-equipped and it was claimed that no
       doctor accompanied her in the said van. It was alleged that Dr. GS
       Kochhar, the husband of Dr. Kanwarjit Kochhar, who represented
       Deep Nursing Home, Chandigarh, chose to follow the van in his car
       separately and, therefore, there was no qualified doctor in the van.
7.     Thus, the specific allegations levelled against the nursing home
       and the doctor were that the nursing home was not equipped to
       handle emergencies and complications during deliveries; the record
       of the treatment was fabricated later to escape prosecution; the
       blood group of Charanpreet Kaur was not checked and this led to
       delay in blood transfusions; the death of the newborn child was
       also due to negligence; there was negligence in causing trauma
       to Charanpreet Kaur by informing her of the death of the newborn
       which resulted in shock and bleeding; and the nursing home had
       no stock of blood readily available for transfusion. The complainants
       sought compensation of ₹95,21,000/- along with interest @ 18% per
       annum, medical expenses of ₹10,000/- and litigation expenses of
       ₹11,000/-. This complaint case was filed on 11.05.2006.
8.     A lengthy written statement was filed by the opposite parties, viz.,
       Deep Nursing Home and Dr. Kanwarjit Kochhar. Therein, they pointed
       out that Manmeet Singh Mattewal had earlier reported the matter to
       the Senior Superintendent of Police, Chandigarh, and an enquiry was
       conducted by a Medical Board, consisting of experts, to ascertain
       whether there was any medical negligence and the Board had negated
       the same. It was stated that Charanpreet Kaur had suffered atonic
       Post Partum Haemorrhage5 which proved to be catastrophic as she
       did not respond to the treatment administered in the nursing home.
       It was stated that PPH is a failure of the uterus to properly contract
       after the child is born resulting in bleeding within the uterus, which
       cannot be controlled. It was asserted that proper treatment was
       given as per protocol but despite the same, she did not respond and
       ultimately died. Details were given of the experience and expertise
       of Dr. Kanwarjit Kochhar and the well-equipped status of the nursing


5    for short, ‘PPH’
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      home. It was stated that Dr. GS Kochhar, who ran the nursing home,
      was a renowned anaesthetist. Charanpreet Kaur was stated to have
      come to the nursing home on 10.11.2005 along with her mother and
      another person. Her date of delivery was approximated to be around
      02.01.2006. As she wanted to have her delivery at the nursing home
      with Dr. Kanwarjit Kochhar, she was advised to continue with the
      intake of Iron and Calcium. It was stated that Charanpreet Kaur did
      not show the reports of her earlier check-ups, despite being asked
      by Dr. Kanwarjit Kochhar, and neither did she show records of her
      previous delivery. It was further stated that Dr. Kanwarjit Kochhar
      came to know from the hushed tones of Charanpreet Kaur that there
      was some problem in the delivery of the first child, but this was not
      divulged to her. She claimed that she later came to know that the
      first child was autistic, but this was also not disclosed to her. She
      asserted that, had this fact come to her knowledge earlier, she
      might have refused to undertake the delivery, as there were more
      chances of the second child having congenital abnormalities if the
      first child had them.
9.    The written statement then went on to state as follows: Charanpreet
      Kaur’s check-ups were on 29.11.2005 and 09.12.2005. As per their
      advice, Charanpreet Kaur had informed them that she had consulted
      a cardiologist but she did not show any report thereof. Again, on
      16.12.2005, Charanpreet Kaur came for a routine check-up and
      was advised to continue with her earlier medication. On 21.12.2005,
      at about 11.00 AM, Charanpreet Kaur was admitted in the nursing
      home as she was suffering from back pain, but she was not in
      labour. Labour was induced and she was making good progress. At
      about 01.00 AM on 22.12.2005, she was having strong contractions.
      Dr. RP Bansal, a qualified paediatrician, was present with the patient
      from 02.15 AM onwards. The delivery took place at 02.40 AM, but
      the newborn child did not cry. The baby was handed over to the
      paediatrician for resuscitation and oxygen was administered through
      a nasal tube. However, all efforts to save the baby failed and he was
      declared dead at 03.10 AM. The mother was not informed about the
      death of the baby. The near relations were informed about it and
      were advised to get an autopsy done to ascertain the exact cause
      of death of the child. However, they refused to do so.
10. Details were furnished of the treatment given to Charanpreet Kaur
    post-delivery and it was stated that there were no placental tissue or
[2025] 10 S.C.R.                                                        33

                     Deep Nursing Home and Another v.
                     Manmeet Singh Mattewal and Others

     membranes in her uterus. The cervix was also examined and no tear
     was found. However, as there was still bleeding, her relations were
     asked to secure two units of blood from the blood bank in Sector 37,
     Chandigarh. Dr. GS Kochhar telephonically informed the blood bank
     to keep the same ready without delay. Transfusion was commenced
     at about 04.15 AM. Owing to the complications which had arisen, two
     more doctors, viz., a senior Gynaecologist and a General Surgeon
     were contacted, and they reached the nursing home at 04.00 AM. All
     the doctors present conducted a thorough examination and opined
     that the patient was suffering from uterine inertia PPH and it was
     decided that she should be sent to the PGI. The staff of the septic
     labour room at the PGI were informed in advance to be ready to
     receive and treat her. She was shifted in an ambulance with running
     blood transfusion and an Ambu bag (oxygen). Two staff nurses from
     the nursing home accompanied her while Dr. GS Kochhar went
     there in his own car. He personally took the patient on a stretcher
     to the septic labour room. On his request, completion of the other
     formalities prior to admission were kept on hold. During the journey,
     the patient suffered a bout of bleeding and was in deep shock. After
     reaching the PGI, she was examined but no pulse and heart beat
     were palpable. Despite resuscitative measures, she did not survive.
     The patient developed uterine inertia PPH which is a disorder with
     poor prognosis and high mortality. Uterine Artery Embolization facility
     was available only in the PGI in the whole of North India. The blood
     group of Charanpreet Kaur was checked and the same was written
     on the prescription dated 10.11.2005 itself, which had been filed with
     the complaint. It was denied that the nursing home was ill-equipped
     to handle emergencies during deliveries. It was asserted that there
     was no delay in shifting the patient to the PGI.
11. No rejoinder was filed by the complainants to the above written
    statement.
12. The SCDRC, vide its judgment dated 31.01.2007, found fault with
    Dr. Kanwarjit Kochhar for not getting Charanpreet Kaur’s blood group
    identified at the time of delivery and in arranging for transfusion by
    keeping blood supply ready. Reference was made to a textbook on
    Obstetrics and Gynaecology by the SCDRC and it was opined that,
    in a case of PPH, excessive bleeding after child birth is the single
    largest cause of maternal deaths worldwide. The SCDRC came to
34                                                       [2025] 10 S.C.R.

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      the conclusion that the nursing home and Dr. Kanwarjit Kochhar
      wasted almost two hours in getting blood and cross-matching it and
      this led to deterioration of the patient’s condition. Examining the
      averments in the written statement, the SCDRC found fault with Dr.
      GS Kochhar for not accompanying the patient in the ambulance to the
      PGI. The SCDRC went to the extent of doubting his very presence
      there. The conclusion drawn by the SCDRC was that Charanpreet
      Kaur was already dead when she was taken to the PGI and this
      was done only to dump her dead body there. The affidavit filed by
      Dr. GS Kochhar was held to be a false and fabricated document
      and the SCDRC categorically recorded a finding that he did not go
      to the PGI. Reference was made to the Report dated 18.08.2006
      of the Medical Board at Government Medical College and Hospital,
      Sector 32, Chandigarh, which opined that ‘there did not appear any
      gross medical negligence in the management of the patient by the
      treating doctors’ but the same was discarded on the ground that it
      was a short report without reasons for recording such a finding. The
      SCDRC held that it was certainly a case of negligence on the part of
      the nursing home and Dr. Kanwarjit Kochhar and they had failed to
      exercise due care and caution in treating Charanpreet Kaur, even if
      it was presumed that there was no fault on their part insofar as the
      death of the child was concerned. The SCDRC, accordingly, directed
      payment of compensation as stated hereinabove.
13. In appeal, as demonstrated by the impugned order, the NCDRC
    observed that Charanpreet Kaur’s death was investigated quite
    thoroughly by successive Medical Boards, appointed specifically for
    that purpose on complaints of gross negligence made by Manmeet
    Singh Mattewal to various authorities of the State Government.
    Before the NCDRC, it was stated on behalf of the appellants that
    the delivery was complete only at about 03.00 AM after the patient
    expelled the placenta. It was contended that in a normal delivery, as
    was the case here, the uterus would gradually contract on its own
    after the delivery and the bleeding would stop but, in this case, the
    uterus did not contract fully and went into a phase of relaxation after
    the initial contraction. It was stated that, the unusual nature of the
    bleeding could be known only after it was verified that it was not from
    any tear in the vagina or the cervix or from the site of the episiotomy
    and all this took some time, as detailed in the medical record. It
    could be concluded only around 03.15 AM that the uterus had not
[2025] 10 S.C.R.                                                         35

                     Deep Nursing Home and Another v.
                     Manmeet Singh Mattewal and Others

     contracted. It was pointed out that, in the course of a normal delivery,
     units of blood are not kept ready for transfusion and, therefore,
     the assumption of the SCDRC, that there was delay and that the
     time taken to get the blood was two hours, was factually incorrect.
     It was asserted that the patient’s medical record showed that the
     transfusion was started in less than an hour of the diagnosis of the
     possible cause of bleeding, i.e., atonic uterus. It was also pointed
     out that the SCDRC’s conclusion that the patient’s blood group was
     not recorded was erroneous. The first page of the medical record
     showed that the patient’s blood group was noted right at the beginning
     but before starting blood transfusion, every unit of blood has to be
     necessarily cross-matched with that of the patient, and this was done
     in the present case also. It was asserted that there was no delay in
     shifting the patient to the PGI and that all possible care was taken
     during that process. She was accompanied by two nurses from the
     nursing home with a unit of blood being transfused simultaneously
     on each arm along with oxygen supply. Dr. GS Kochhar preceded
     the van in his car to ensure that there was no delay in taking her to
     the septic labour room. It was pointed out that five Medical Boards
     had examined the case record and concluded that, neither in dealing
     with the newborn’s asphyxia nor in treating the mother for the sudden
     complication of atonic PPH, Dr. Kanwarjit Kochhar had committed
     any act of medical negligence. All the experts who constituted these
     Boards found that there was no negligence on her part or on the
     part of the nursing home.
14. The NCDRC dealt with each of the Medical Board Reports in turn,
    viz., the first Report dated 23.01.2006 by a Board of four doctors
    from the Government Hospital, Sector 16, Chandigarh; the second
    Report dated 20.03.2006 of a Board of five doctors from the
    Government Medical College and Hospital, Sector 32, Chandigarh;
    the third Report dated 03.04.2006 of the reconstituted Committee
    of four doctors from the Government Medical College and Hospital,
    Sector 32, Chandigarh; and the fourth Report dated 18.08.2006 of
    a Committee of seven doctors constituted under the Chairmanship
    of the Director, Health Services, Union Territory, Chandigarh. The
    undated fifth and final Report of four doctors was also from the
    Government Medical College and Hospital, Sector 32, Chandigarh,
    but it was not taken note of by the NCDRC.
15. The NCDRC, thereupon, looked into medical literature and copiously
    extracted from such literature in its order. It noted that Charanpreet
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      Kaur was under the medical care of Dr. Kanwarjit Kochhar from the
      32nd week of her pregnancy through childbirth. It was noted that she
      had gone to some other Obstetrician during the earlier part of her
      second pregnancy. Noting the claim made by Dr. Kanwarjit Kochhar
      that she was not told details of the delivery of the first child but
      her suspicion that there was some problem therewith, the NCDRC
      observed that it was the minimum professional requirement for her
      to have gathered such information. The NCDRC also found fault with
      the medical record maintained by the nursing home after Charanpreet
      Kaur’s first visit. It was noted that Dr. Kanwarjit Kochhar had claimed
      that the prior medical record was not given to her and the NCDRC
      opined that she had failed to ascertain information which had crucial
      implications, i.e., with regard to Charanpreet Kaur’s haematological
      status. We may observe, at this stage, that the NCDRC seems to have
      visualized itself in the role of a medical professional and expressed
      purported expert opinions on how Dr. Kanwarjit Kochhar ought to
      have acted as an Obstetrician when Charanpreet Kaur came to her
      initially and as to how she should have gone about prescribing tests!
16. In effect, the NCDRC opined that, though all the Medical Boards
    had opined that there did not appear to be any gross medical
    negligence in the management of the patient by the treating
    doctors after the delivery, the same did not mean that there was no
    medical negligence before the delivery. As per the NCDRC, there
    were several instances of departure from standard protocols in the
    antenatal care of the patient on the part of Dr. Kanwarjit Kochhar as
    she failed to insist on the patient getting standard haematological
    investigations done. According to the NCDRC, no case of tortious
    medical negligence was made out against Dr. Kanwarjit Kochhar
    in handling Charanpreet Kaur’s labour, including the delivery, the
    management of the baby, the baby’s problem and the post-delivery
    management at the nursing home, but there was enough evidence
    as well as expert opinion to hold that antenatal management of
    Charanpreet Kaur by Dr. Kanwarjit Kochhar, particularly, in respect
    of necessary haematological and cardiological investigations, was
    not in accordance with the standard protocols that an Obstetrician
    of average skill would adopt. It further held that no case of medical
    negligence/ deficiency in service was made out against the nursing
    home as there was nothing in the Medical Boards’ Reports on this
    aspect and the complainants did not lead any reliable evidence in
[2025] 10 S.C.R.                                                        37

                     Deep Nursing Home and Another v.
                     Manmeet Singh Mattewal and Others

     support of their allegations in this regard. The NCDRC, therefore,
     concluded that no liability could attach to the nursing home. The
     NCDRC noted that, pursuant to its direction on 12.04.2007, Manmeet
     Singh Mattewal had withdrawn ₹6,00,000/- deposited by the nursing
     home and the insurance company and directed that the balance
     amount due be paid by Dr. Kanwarjit Kochhar.
17. It would be apposite at this stage to note the contents of the Medical
    Boards/Committees’ Reports. The first Report dated 23.01.2006
    was furnished by the Board of doctors from Government Hospital,
    Sector 16, Chandigarh. This Board comprised Dr. Rupinder Kaur, Dr.
    Vidhu Bhasin and Dr. N.K. Kaushal. After perusing the record, the
    Board opined that the patient had died because of severe atonic PPH
    which did not respond to the treatment given at the nursing home.
    It was recorded that the treatment given was as recommended and
    that blood is not arranged beforehand for normal deliveries. It was
    noted that the blood samples were sent for cross-matching at 03.15
    AM; that the patient went into shock at 03.45 AM, that blood was
    brought from Rotary and Blood Bank Society, Sector 37, Chandigarh;
    that blood transfusion was started at 04.15 AM on both arms; and
    she was then referred to the PGI.
18. The second Report dated 20.03.2006 was from a Board of doctors of
    Government Medical College and Hospital, Sector 32, Chandigarh.
    The doctors in this Board were Professor Veena Parmar, HoD of
    Paediatrics; Professor Anju Huria, HoD of Obstetrics & Gynaecology;
    Professor K.K. Gombar, HoD of Anaesthesia; Professor A.K. Attri,
    HoD of Surgery; and Professor Harsh Mohan, Medical Superintendent
    and HoD of Pathology (Chairman). The conclusion of the Board was
    that the patient had atonic PPH which was managed conservatively
    but without success. It was noted that PPH is a known complication
    of delivery and accounted for 8% of maternal mortality in developed
    countries. The Board opined that different patients may cope differently
    with blood loss in PPH - a healthy woman would be far more tolerant
    to blood loss of 30-50% when compared to a woman with either
    pre-existing anaemia or underlying cardiac complications or pre-
    eclampsia. The Board opined that it could not be said with certainty
    from the record whether this patient had anaemia or hypotension and
    shock before delivery but in the presence of either or both of these
    conditions, atonic PPH was more likely to be catastrophic. This final
38                                                         [2025] 10 S.C.R.

                         Supreme Court Reports


      conclusion of the Board did not indict Dr. Kanwarjit Kochhar but left
      the question open as it was not clear from the record whether the
      patient had any of these conditions before the delivery.
19. The third Report dated 03.04.2006 was submitted by a Committee
    of doctors from the Government Medical College and Hospital,
    Sector 32, Chandigarh, comprising Professor A.K. Attri, HoD of
    Surgery (Chairman); Dr. Satinder Gombar, Professor and HoD of
    Anaesthesia; Dr. Anju Huria, HoD of Obstetrics & Gynaecology; and
    Dr. Suksham Jain, Assistant Professor of Paediatrics. This Committee,
    after perusing the record submitted by the Office of the Director, Health
    and Welfare, Chandigarh Administration, discussed the previous
    reports submitted by the teams of doctors from the General Hospital,
    Sector 16, Chandigarh, and the Government Medial College and
    Hospital, Sector 32, Chandigarh, and upon perusal of the medical
    record and the medical reports and after thorough deliberations, the
    Committee opined that there was no gross medical negligence in
    the management of the patient.
20. The fourth Report from the Government Medical College and
    Hospital, Sector 32, Chandigarh was dated 18.08.2006. This report
    was consequential to the letter dated 15.06.2006 of the Senior
    Superintendent of Police, Union Territory, Chandigarh. This Committee
    consisted of Dr. Manjit Singh Bains, Director, Health Services,
    General Hospital, Sector 16, Chandigarh (Chairman); Dr. Usha
    Bishnoi, Medical Superintendent, General Hospital, Chandigarh;
    Professor Harsh Mohan, Medical Superintendent, Government
    Medical College and Hospital, Sector 32, Chandigarh; Professor
    K.K. Gombar, HoD of Anaesthesia; Professor Veena Parmar, HoD
    of Paediatrics; Professor Anju Huria, HoD of Gynaecology.; and Dr.
    A.K. Attri, HoD of Surgery. The Committee deliberated on the issue
    addressed in the letter and considered the records of the deceased
    mother and child provided by the police department. The Committee
    also discussed the reports submitted previously by the teams of
    doctors from the General Hospital, Sector 16, Chandigarh, and the
    Government Medical College and Hospital, Sector 32, Chandigarh.
    After considering the said records and reports, the Committee opined
    that there did not appear to be any gross medical negligence in the
    management of the patients by the treating doctors.
21. The fifth and final undated Report was also from the Government
    Medical College and Hospital, Sector 32, Chandigarh. This Committee
[2025] 10 S.C.R.                                                        39

                     Deep Nursing Home and Another v.
                     Manmeet Singh Mattewal and Others

     comprised Professor A.K. Attri, HoD of Surgery (Chairman); Dr.
     Satinder Gombar, Professor and HoD of Anaesthesia; Dr. Anju
     Huria, HoD of Obstetrics and Gynaecology; and Dr. Suksham Jain,
     Assistant Professor of Paediatrics. The Committee perused the whole
     record submitted by the Office of the Director, Health and Welfare,
     Chandigarh Administration, and discussed the previous reports
     submitted by the teams of doctors. After thorough deliberations and
     perusal of the medical records and the reports, the Committee opined
     that there was no gross medical negligence in the management of
     the patients.
22. Significantly, all the above reports came about upon the instigation
    and at the behest of Manmeet Singh Mattewal himself, who seems
    to have approached various authorities voicing his grievance against
    Dr. Kanwarjit Kochhar and the nursing home in relation to the death
    of his wife and child. However, except for one report which, owing
    to lack of sufficient data, left one question open, i.e., the possible
    pre-existing conditions that may have led to the death of Charanpreet
    Kaur, none of the reports held Dr. Kanwarjit Kochhar negligent. Further,
    given the settled legal position that every failure in the treatment of
    a patient does not automatically lead to an assumption of medical
    negligence, we find that the opinions expressed by the doctors and
    experts, who constituted these Medical Boards/Committees, clearly
    tilted the balance in favour of Dr. Kanwarjit Kochhar, as none of
    them found any medical negligence on her part. As already noted
    hereinbefore, these bodies were constituted at the behest of Manmeet
    Singh Mattewal himself and he cannot, therefore, fight shy of the
    conclusions and findings rendered by them.
23. As pointed out in Jacob Mathew vs. State of Punjab and another6,
    simply because a patient did not favourably respond to the treatment
    given by a physician or if a surgery failed, the doctor cannot be held
    liable per se by applying the doctrine of res ipsa loquitur. This edict
    was reiterated in Martin F. D’Souza vs. Mohd. Ishfaq7 wherein, it
    was pointed out that no sensible professional would intentionally
    commit an act or omission which would result in harm or injury to
    a patient as the reputation of that professional would be at stake


6   (2005) 6 SCC 1
7   (2009) 3 SCC 1
40                                                       [2025] 10 S.C.R.

                                Supreme Court Reports


       and a single failure may cost him or her dear in that lapse. It was
       also pointed out that sometimes, despite best efforts, the treatment
       by a doctor may fail but that does not mean that the doctor or
       surgeon must be held guilty of medical negligence, unless there
       is some strong evidence to suggest that he or she is. It was also
       pointed out that Courts and Consumer Fora are not experts in
       medical science and must not substitute their own views over that
       of specialists. While acknowledging that the medical profession had
       been commercialised to some extent and there were doctors who
       depart from their Hippocratic Oath for their selfish ends of making
       money, this Court held that the entire medical fraternity cannot be
       blamed or branded as lacking in integrity or competence just because
       of some bad apples.
24. On the same lines, in Devarakonda Surya Sesha Mani and
    others vs. Care Hospital, Institute of Medical Sciences and
    others8, it was held that unless a complainant is able to establish a
    specific course of conduct, suggesting a lack of due medical attention
    and care, it would not be possible for the Court to second-guess
    the medical judgment of the doctor on the line of treatment which
    was administered and, in the absence of such material disclosing
    medical negligence, the Court cannot form a view at variance, as
    every death in the institutionalised environment of a hospital does
    not necessarily amount to medical negligence on a hypothetical
    assumption of lack of due medical care.
25. In any event, the NCDRC’s ultimate conclusion was that there was
    negligence on the part of Dr. Kanwarjit Kochhar only in the antenatal
    care and management of Charanpreet Kaur. More importantly, the
    NCDRC rendered a clear finding that there was no medical negligence
    in the handling of Charanpreet Kaur’s labour, including her delivery;
    the management of the baby’s problem; and the post-delivery
    management at the nursing home. These conclusions, arrived at
    by the NCDRC, not only reversed the findings of the SCDRC but
    also turned the very case put forth by the complainants on its head.
    In fact, the NCDRC decided the matter by building up a new case
    altogether!



8     2022 SCC OnLine SC 1608
[2025] 10 S.C.R.                                                       41

                     Deep Nursing Home and Another v.
                     Manmeet Singh Mattewal and Others

26. The specific claim of Manmeet Singh Mattewal in Complaint Case
    No. 56 of 2006 was that there was medical negligence on the
    part of Dr. Kanwarjit Kochhar and the nursing home in the post-
    delivery treatment only, as sufficient facilities were not available in
    the nursing home to deal with post-delivery emergencies, and Dr.
    Kanwarjit Kochhar failed to take adequate care and caution after
    the delivery to save the life of the patient. He categorically asserted
    that the nursing home was ‘inadequately and ill equipped’ to handle
    emergencies during deliveries and there were no facilities available
    in that regard. His further allegation was that Charanpreet Kaur
    was informed about the death of the newborn child which resulted
    in her going into shock and caused profuse bleeding. However, this
    was not proved and neither the SCDRC nor the NCDRC recorded
    a finding on this aspect. His further allegation was that there was
    delay in arranging for blood transfusions and there was negligence
    during the transfer of Charanpreet Kaur from the nursing home to
    the PGI. He made no allegations whatsoever to the effect that the
    antenatal care and management of Charanpreet Kaur were deficient
    in any manner. On the contrary, he specifically asserted that various
    tests were prescribed by Dr. Kanwarjit Kochhar and Charanpreet
    Kaur underwent all such tests.
27. The SCDRC had accepted Manmeet Singh Mattewal’s case and held
    that negligence was attributable to Dr. Kanwarjit Kochhar and the
    nursing home in relation to the post-delivery care and treatment of
    Charanpreet Kaur. However, this finding was reversed by the NCDRC,
    as is evident from the impugned order, wherein the NCDRC held in
    clear terms that no liability attached to the nursing home and it was
    Dr. Kanwarjit Kochhar who was to be held responsible on the ground
    of medical negligence in the antenatal care and management. The
    specific finding of the NCDRC was that Dr. Kanwarjit Kochhar had not
    prescribed the requisite haematological tests for Charanpreet Kaur.
28. This was never the case of Manmeet Singh Mattewal. The entire
    focus of the NCDRC, however, was only upon the antenatal care
    and management of the patient and its pinpointed findings were
    also in relation to the said period and treatment only. The NCDRC’s
    observation that there were several instances of departure from
    standard protocols in the antenatal management of the patient, such
    as, not getting proper tests done, and its final finding that no case
42                                                         [2025] 10 S.C.R.

                                Supreme Court Reports


       of tortious medical negligence was made out against Dr. Kanwarjit
       Kochhar in handling Charanpreet Kaur’s labour, her delivery,
       management of the baby and his problem, and the post-delivery
       management of both of them at the nursing home, demonstrated
       and settled in no uncertain terms that the case put forth by Manmeet
       Singh Mattewal was not proved and established. Once his case, as
       pleaded and projected, was not made out, the NCDRC clearly erred
       in building up a new case on his behalf and in pinning negligence
       and liability upon Dr. Kanwarjit Kochhar in the context of antenatal
       care and management of the patient, which was never the subject
       matter of the complaint case. In doing so, the NCDRC overstepped
       its power and jurisdiction as it was not for it to travel beyond the
       pleadings in the complaint case and build up a new case on its
       own (See A.V.G.P. Chettiar & Sons and others vs. T. Palanisamy
       Gounder9, Venkataraman Krishnamurthy and another vs. Lodha
       Crown Buildmart (P) Ltd.10, Rama Kt. Barman (Died) Thr. LRs. vs.
       Mohd. Mahim Ali and others11).
29. Useful reference may also be made to the observations of this Court
    in Trojan and Company vs. Rm. N.N. Nagappa Chettiar12, as long
    back as in the year 1953, that it is well settled that the decision of
    a case cannot be based on grounds outside the pleadings of the
    parties and it is the case pleaded that has to be found. Again, in Ram
    Sarup Gupta (Dead) by LRs vs. Bishun Narain Inter College and
    others13, this Court observed that it is well settled that no party should
    be permitted to travel beyond its pleadings and that all necessary
    and material facts should be pleaded by a party in support of the
    case set up by it. It was pointed out that the object and purpose of
    pleadings is to enable the adversary party to know the case it has
    to meet as, in order to have a fair trial, it is imperative that a party
    should settle the essential material facts so that the other party may
    not be taken by surprise.



9     (2002) 5 SCC 337
10    (2024) 4 SCC 230
11    2024 SCC OnLine SC 4083
12    (1953) 1 SCC 456
13    (1987) 2 SCC 555
[2025] 10 S.C.R.                                                      43

                     Deep Nursing Home and Another v.
                     Manmeet Singh Mattewal and Others

30. Viewed thus, the NCDRC clearly transgressed its jurisdiction in
    building a new case for the complainants, contrary to their pleadings.
    However, its finding that there was no negligence in the delivery
    and the post-delivery treatment of Charanpreet Kaur have attained
    finality as no separate appeal was preferred by the complainants.
    The impugned order passed by the NCDRC, confirming the SCDRC’s
    judgment on the new grounds made out by it, therefore, cannot be
    sustained.
31. The appeal is accordingly allowed, setting aside the order dated
    09.05.2012 passed by the National Consumer Disputes Redressal
    Commission, New Delhi, in First Appeal Nos. 158 and 193 of
    2007, as well as the judgment dated 31.01.2007 passed by the
    State Consumer Disputes Redressal Commission, Union Territory,
    Chandigarh, in Complaint Case No. 56 of 2006. In consequence,
    the said complaint case shall stand dismissed.
     Manmeet Singh Mattewal, respondent No. 1, shall return and refund
     the sum of ₹10,00,000/- received by him, pursuant to the orders
     passed in this litigation, to Dr. Kanwarjit Kochhar, Dr. GS Kochhar
     and New India Assurance Company Ltd. in monthly instalments
     of ₹1,00,000/- each. The first three instalments, aggregating to
     ₹3,00,000/-, shall be paid to New India Assurance Company Ltd.
     and the balance sum of ₹7,00,000/- shall be paid to Dr. Kanwarjit
     Kochhar and Dr. GS Kochhar under acknowledgement, as we are
     informed that the nursing home is no longer in existence.
     In the circumstances, parties shall bear their own costs.

     Result of the case: Appeal allowed.




     †
         Headnotes prepared by: Ankit Gyan