Holding

The doctors cannot be prosecuted under Section 304A as the death resulted from non‑availability of an oxygen cylinder and the requisite gross negligence was not established.

Summary

The appellant, Dr. Jacob Mathew, was charged under Section 304A IPC for the death of a patient who died after an empty oxygen cylinder was attached to him in a private hospital. The trial court framed charges and the High Court dismissed the petition to quash the FIR. On appeal, the Supreme Court examined whether the death could be attributed to criminal negligence of the doctors. It held that criminal liability under Section 304A requires a rash or negligent act of a gross degree, assessed by the Bolam test, and that the non‑availability of an oxygen cylinder – a failure of the hospital’s equipment – does not constitute gross professional negligence. The Court also ruled that res ipsa loquitur cannot be used to determine criminal liability. Consequently, the prosecution was quashed and the appeal allowed.

Issues considered

Whether the death caused by an empty oxygen cylinder can be attributed to criminal negligence under Section 304A IPC.
Whether the standard of care for doctors in criminal negligence cases is governed by the Bolam test.
Whether gross negligence is a necessary element for liability under Section 304A.
Whether the doctrine of res ipsa loquitur is applicable in criminal negligence proceedings.
What procedural safeguards should govern the prosecution of medical professionals for criminal rashness or negligence.

Legislation cited

Code of Criminal Procedures. 482
Consumer Protection Acts. 1986
Indian Penal Code, 1860s. 304A, s. 34, s. 88, s. 92, s. 93

Subjects

medical negligencecriminal negligenceSection 304A IPCgross negligenceBolam testres ipsa loquiturdoctor liabilitycriminal law vs civil lawguidelines for prosecution of doctors

Judgment

JACOB MA THEW A
V.

STATE OF PUNJAB AND ANR.

AUGUST 5, 2005

[R.C. LAHOTI CJ., G.P. MATHUR AND B
P.K. BALASUBRAMANY AN, JJ.]

Penal Code 1860,

Sections 304-A, 88, 92, 93~riminal liability for Medical Negligence-
Death due to medical negligence-Criminal liability of doctor-Held, to C
prosecute a medical professional for criminal negligence it must be shown
that the accused doctor did something or failed to do something which in the
given/acts and circumstances no medical professional in his ordinary senses
and prudence would have done or failed to .do-Hazard taken by the accused
doctor should be of such a narure that the resultant i'?iury was most likely D
imn1inent-Onfacts, held, doctor can not be p1oceeded against under S. 304-
A as it is a case ofnon-availability of oxygen cylinder-Rationale for special
treatment of doctors discussed in detail and guidelines laid down to protect
interest of doctors, and to save the1n from unwarranted and malicious
proceedings.
E
Sections 304-A, 88, 92, 93-Mens rea in criminal negligence-Held,
for negligence to amounl to a crinzinal offence, the element o/mens rea must
be shown to exist-Recklessness, i. e. disregard/or the possible consequences,
constitutes the mens rea in criminal negligence.

Section 304-A-Negligence-As a tort and criminal negligence-Nature F
of Negligence required-Held, to fasten liability in criminal law, degree of
negligence has to be higher than negligence enough to fasten liability for
damages in civil law-For criminal libility, the negligence has to be gross
or of a very high degree-Expression "rash and negligent act" to be reads
9ualified by "grossly". G
304-A-liabi/ity under-When attracted-Held, death must be direct
result of act of accused-Such act must be causa causans-Not enough if
it is cause sine qua non-Criminal Law-Negligence-Causation.

Section 304-A-Res ipsa loquitor-Applicabi/ity in criminal law- H
307
308 SUPREME COURT REPORTS [2005] SUPP. 2 S.C.R.

A Held, this rule cannot be applied for determining per se the liability for
negligence in criminal law and case under section 304-A cannot be decided
solely by applying this rule.

Tort-Professional neg!igence-Scope of-Held, a professional may be
held liable for negligence if he was not possessed of the requisite skill which
B he professed to have possessed, or he did not exercise the skill which he
possessed with reasonable competence in the given case-Standard of care
required is of the ordinary competent person exercising ordinary skill in that
profession-Test laid down in Bolam's case held, applicable in India.

C Professional negligence distinguished from occupational negligence.

Tort-Negligence-Medical Neglicence-Detailed explanation of when
devation from normal medical practice would amount to evidence ofmedical
negligence.

D Tort-Negligence-Res ipsa loquitor-Application to Medical
·Practioners-Held, has to be applied with extreme care and caution to the
cases of medical negilgence.

Complainant's father was admitted to the hospital. He felt difficulty
in breathing. Duty nurse called some doctor to attend to the patient. No
E doctor turned up for 20-25 minutes. Then the appellant and another
doctor came to the patients room. An oxygen cylinder was brought and
connected to the mouth of the patient but the breathing problem increased
further. The oxygen cylinder was found to be empty. There was no other
gas cylinder available. Later, the patient was declared dead. An offence
F under sections 304-A/34 Penal Code, 1860 was registered and charges
. filed against the doctors. Doctor's petition to High Court to quash the -
charges was dismissed. Hence the appeal.

Allowing the appeal, the Court

G HELD : 1.1. Negligence in the context of medical profession
necessarily calls for a treatment with a difference. To infer rashness or
negligence on the part ofa professional, in particular a doctor, additional
considerations apply. A case of occupational negligence is different from
one of professional negligence. A simple lack of care, an error of judgment
H or an accident, is not proof of negligence on the part of a medical
JACOB MATHEW v. STATE 309

professional. So long as a doctor follows a practice acceptable to the A
medical profession of that day, he cannot be held liable for negligence
merely because a better alternative course or method of treatment was
also available or simply because a more skilled doctor would not have
chosen to follow or resort to that practice or procedure which the accused
followed. When it comes to the failute of taking precautions what ha• to
B
bee seen is whether those precautions were taken which the ordinary
experience of men has found to be sufficient; a failure to use special or
extraordinary precautions which might have prevented the particular
happening cannot be the standard for judging the alleged negligence. So
also, the standard of care, while assessing the practice as adopted, is
judged in the light of knowledge available at the time of the incident, and c
not at the date of trial. Similarly, when the charge of negligence arises
out of failure to use some particular equipment, the charge would fail if
the equipment was not generally available at that particular time (that
is, the time of the incident) at which it is suggested it should have been
used. [338-B-F]
D
1.2. A professional may be held liable for negligence on one of the two
findings: either 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 he did possess. The standard to be applied for
judging, whether the person charged has been negligent or not, would be E
that of an ordinary competent person exercising ordinary skill in that
profession. It is not possible for every professional to posses th~ highest
level of expertise or skills in that branch which he practices. A highly skilled
professional may be possessed of better qualities, but that cannot be made
the basis or the yardstick for judging the performance of the professional
proceeded against on indictment of negligence. The test for determining
F
medical negligence as laid down in Bo/am 'scase [1957] 1W.L.R.582, holds
good in its applicability in India. [338-F-H; 339-A]

Micheal Hyde and Associates v. J.D. William & Co., (2001] Pt/LR 233;
Bo/am v. Friern Hospital Management Committee, [1957] !WLR 582 G
Eckersley v, Binnie, [1988] 18 Con LR I; Hucks v. Cole, [1968] 118 New
LJ 469; Maynard v. West Midlands Regional Health Authority, (1985] 1 All
ER 635 and Hunter v, Hanley, [1995] SLT 213, relied on.

Suresh Gupta (Dr.) v. Govt. ofNCTof Delhi, [2004] 6 SCC 422; John
Oni Akerele v. R., AIR (1943) PC 72; Kurban Hussein Mohammedali H
310 SUPREME COURT REPORTS [2005] SUPP. 2 S.C.R.

A Rangwalla v. State of Maharashtra, [1965) 2 SCR 622; Kishan Chand v.
State of Haryana, (1970) 3 SCC 904; Juggankhan v. State of MP., [1965)
I SCR 14 and Emperor v. Omkar Rampratap, (1902) 4 Born LR 679, relied
on.

Dr. Laxman Balkrishna Joshi v. Dr. Trimbak Bapu Godbole, (1969) 1
B SCR 206; Indian Medical Association v. VP. Shantha, [1995) 6 SCC 651;
Poonam Verma v. Ashwin Patel, (1996) 4 SCC 332; Achutrao Haribhau
Khodwa v. State of Maharashtra, (1996) 2 SCC 634; Spring Meadows
Hospital v. Harjot Ahluwalia, [1998) 4 SCC 39; Whitehouse v. Jorden,
(1981) 1 ALL ER 267 and State of Haryana v. Santra, (2005) 5 SCC 182,
c referred to.

2.1. The jurisprudential concept of negligence differs in civil and
criminal law. What may be negligence in civil law may not necessarily
be negligence in criminal law. Generally speaking, it is the amount of
damages incurred which is determinative of the extent of •iability in tort;
D but in criminal law it is not the amount of damages but the am.ount and
degree of negligence that is determinative of liability. For negligence to
amount to an offence, the element of mens rea must be shown to exist. It
is recklessness that constitutes mens rea in criminal law as far as negligence
is concerned. The moral culpability of recklessness is not located in a
desire to cause harm. It resides in the proximity of the reckless state of
E mind to the state of mind present .when there is an intention to cause
harm. There is, in other words, a disregard for the possible consequences.
For an act to amount to criminal negligence, the degree of negligence
should be much higher i.e. gross or of a very high degree. Negligence
which is neither gross nor of a higher degree may provide a ground for
F action in civil law but cannot form the basis for prosecution.
[318-C, E, H; 319-A; 320-C; 339-A-B)

2.2. The word 'gross' has not been used in Section 304A of IPC, yet
it is settled that in criminal law negligence or recklessness, to be so held,
must be of such a high degree as to be 'gross'. The expression 'rash or
G negligent act' as occurring in Section 304A of the IPC has to be read as
qualified by the word 'grossly'. To impose criminal liability under Section
304-A IPC, it is necessary that the death should have been the direct
result of a rash and negligent act of the accused, and that act must be the
proximate and efficient cause without the intervention of another's
H negligence. [332-C-D; 339-C-D)
JACOB MATHEW v. STATE 311

2.3. To prosecute a medical professional for negligence under criminal A
law it must be shown that the accused did something or failed to do
something which in the given facts and circumstances no medical
professional in his ordinary senses and prudence would have done or
failed to do. The hazard taken by the accused doctor should be of such
a nature that the injury which resulted was most likely imminent. B
[339-D-E]

R. v. Lawrence, [1981] 1 All ER 974; R. v. Caldwell, [1981] 1 All ER
961;

Andrews v. Director of Public Prosecutions, (1937) AC 576; Syad C
Akbarnr v. State of Karnataka, [1980] 1 SCC 30; Reg v. lndu Beg, [1881]
3All 776 Riddell v. Raid, [1942] 2 All ER 161; Bhalc~andra Waman Pathe
v. State of Maharashtra, (1968) Mah LJ 423 (SC), relied on.

Roscoe's Law of Evidence (15th Edn.), pp. 848-49; "Speeches and
Poems with the Report and Notes on the Indian Penal Code" by Lord D
Macaulay (Houghton Mijjlin and Company, published in 1874), pp. 419, 421
& 422; Alan Merry and Alexander McCall Smith Errors, Medicine and the
Law (Cambridge University Press, 2001), pp. 241-248, relied on.

3. Res ipsa loquitur is only a rule of evidence and operates in the
domain of civil law specially in cases of torts and helps in determining E
the onus of proof in actions relating to negligence. It cannot be pressed
in sen•ice for determining per se the liability for negligence wi'~in the
domain of criminal law. Res ipsa loquitur has, ifat all, a limited application
in trial on a charge of criminal negligence. [339-E-F]

Syad Akbar v. State of Karnataka, [1980] I SCC 30, relied on F
Krishnan v. State of Kera/a, [1996] 10 SCC 508, explained,

4. To protect the interest of doctors and to save them from
unwarranted and malicious proceedings, statutory Rules or Executive
Instructions incorporating certain guidelines need to be framed and G
issued by the Government of India and/or the State Governments in
consultation with the Medical Council or India. So long as it is not done,
the following guidelines will be in force which should govern the prosecution
of doctors for offences of which criminal rashness or criminal negligence
is an ingredient. A private complaint may not be entertained unless the H
312 SUPREME COURT REPORTS [2005] SUPP. 2 S.C.R.

A complainant has produced prima facie evidence before the Court in the
form of a credible opinion given by another competent doctor to support
the charge of rashness or negligence on the part of the accused doctor.
The investigating officer should, before proceeding against the doctor
accused of rash or negligent act or omission, obtain an independent and
B competent medical opinion preferably from a doctor in government service
qualified in that branch of medical practice who can normally be expected
to give an impartial and unbiased opinion applying Bo/am 's test to the
facts collected in the investigation. A doctor accused of rashness or
negligence, may not be arrested in a routine manner, unless his arrest is
necessary for furthering the investigation or for collecting evidence or
c unless the investigation officer feels satisfied that the doctor proceeded
against would not make himself available to face the prosecution unless
arrested. (340-F-H; 341-A-B)

5. In the present case all the averments made in the complai•u, even
D if held to be proved, do not make out a case of criminal rashness or
negligence on the part of the accused-appellant. It is not the case of the
complainant that the accused-appellant was not a doctor qualified to
treat the patient whom he agreed to treat. It is a case of non-availability
of oxygen cylinders either because of the hospital having failed to keep
available a gas cylinder or because ofthe gas cylinder being found empty.
E Then, probably the hospital may or may not be liable in civil law but the
accused-appellant cannot be proceeded against under Section 304-A IPC
on the parameters of the Bo/am test. (341-C-E)

CRIMINAL APPELLATE WRISDICTION Criminal Appeal No~
F 144-145 of 2004.

From the Judgment and Order dated 18.12.2002 and 24.1.2003 of the
Punjab and Haryana High Court in Cr!. Misc. No. 21940-M of 1999 and Crl.
Misc. No. 1984 of 2003.

G G.E. Vahanvati, Rakesh Dwivedi, Ashok H. Desai, Vivek K. Tankha,
Rupinder Singh Suri, Mrs. Gurvinder Suri, Jagjit Singh Chhabra, Atul Nanda,
Addi. Advocate General for State of Punjab, Bimal Roy Jad, P.N. Puri,
Maninder Singh, Kirtiman Singh, Saurabh Mishra, Angad Mirdha, Mrs.
Pratibha M. Singh, Devadatt Kamat, Ms. Rameeja Hakem, Chinmoy Pradip
H Sharma, Hrishikesh Barua, Ms. Suruchi Suri, Ravinder Narain, Ms. Sushma
JACOB MATHEW v. STATE [LAHOTI, CJ.] 313

Shanna, Ms. Meghalee Barthakur, Ms.Kanika Gamber, Rajan Narain, A '
Harekhrishna Upadhyaya, Prashant Kumar, Siddharth Singh Chauhan, Harsh
Pathak, A.A. Maitrya, Praveen Khattar, Mrs. Sudha Gupta, Avik Datt and V.
K. Monga for the appearing parties.

The Judgment of the Court was delivered by B
R.C. LAHOTI, CJ. : Ashok Kumar Sharma, the respondent no. 2
herein filed a First lnfonnation Report with police station, Division No. 3,
Ludhiana, whereupon an offence under Section 304A read with Section 34
of the Indian Penal Code (for short "the !PC") was registered. The gist of
the infonnation is that on 15.2.1995, the infonnant's father, late Jiwan Lal
c
Sharma was admitted as a patient in a private ward of CMC Hospital,
Ludhiana. On 22.2.1995 at about 11 p.m., Jiwan Lal felt difficulty in
breathing. The complainant's elder brother, Vijay Shanna who was present
in the room contacted the duty nurse, who in her turn called some doctor to
attend to the patient. No doctor turned up for about 20 to 25 minutes. Then, D
Dr. Jacob Mathew, the appellant before us and Dr.Allen Joseph came to the
room of the patient. An oxygen cylinder was brought and connected to the
mouth of the patient but the breathing problem increased further. The patient
tried to get up but the medical staff asked him to renrain in the bed. The
oxygen cylinder was found to be empty. There was no other gas cylinder E
available in the room. Vijay Shanna went to the adjoining room and brought
a gas cylinder therefrom. However, there was no arrangement to make the
gas cylinder functional and in-between, 5 to 7 minutes were wasted. By this
time, another doctor came who declared that the patient was dead. The latter
part of the FIR states (as per the translation in English as filed by the F·
complainant):

" ................ the death of my father was occurred due to the
carelessness of doctors and nurses and non availability of oxygen
cylinder and the empty cylinder was fixed on the mouth of my father
and his breathing was totally stopped hence my father died. I sent G
the dead body of my father to my village for last cremation and for
infonnation I have come to you. Suitable action be done Sd/- ----
As per statement of intimater the death of Jiwan Lal Shanna has
occurred due to carelessness of doctors and nurses concerned and
to fit empty gas cylinder." H
314 SUPREME COURT REPORTS [2005] SUPP. 2 S.C.R.

A On the abovesaid report, an offence under Section 304A/34 IPC was
registered and investigated. Challan was filed against the two doctors.

The Judicial Magistrate First Class, Ludhiana framed charges under
Section 304A, IPC against the two accused persons, both doctors. Both of
them filed a revision in the Court of Sessions Judge submitting that there was
B no ground for framing charges against them. The revision was dismissed. The
appellant filed a petition in the High Court under Section 482 of the Code
of Criminal Procedure praying for quashing of the FIR and all the subsequent
proceedings.

c allegation
It was submitted before the High Court that there was no specific
of any act of omission or commission against the accused persons
in the entire plethora of documents comprising the challan papers filed by
the police against them. The learned single Judge who heard the petition
formed an opinion that the plea raised by the appellant was available to be
urged in defence at the trial and, therefore, a case for quashing the charge
D was not made out. Vide order dated 18.12.2002, the High Court dismissed
the petition. An application for recalling the abovesaid order was moved
which too was dismissed on 24.1.2003. Feeling aggrieved by these two
orders, the appellant has filed these appeals by special leave.

According to the appellant, the deceased Jiwan Lal was suffering from
E cancer in an advanced stage and as per the information available, he was,
in fact, not being admitted by any hospital in the country because his being
a case of cancer at terminal stage. He was only required to be kept at home
and given proper nursing, food, care and solace coupled with prayers. But
as is apparent from the records, his sons are very influential persons
F occupying important positions in Government. They requested the hospital
authorities that come what may, even on compassionate grounds their father
may be admitted in the hospital for regulated medical treatment and proper
management of diet. It was abundantly made clear to the informant and his
other relations who had accompanied the deceased that the disease was of
such a nature and had attained such gravity, that peace and solace could only
G be got at home. But the complainant could prevail over the doctors and
hospital management and got the deceased admitted as an in-patient.
Nevertheless, the patient was treated with utmost care and caution and given
all the required medical assistance by the doctors and para-medical staff.
-
Every conceivable effort was made by all the attending staff comprising of
doctors and nurses and other para-medicals to give appropriate medical
H
JACOB MA THEW v. STA TE [LAHOTI, CJ.] 315

treatment and the whole staff danced attendance on the patient but what was A
ordained to happen, did happen. The complainant and his relations, who were
misguided or were under mistaken belief as to the facts, lodged police report
against the accused persons wholly unwarranted and uncalled for.

The matter came up for hearing before a Bench of two learned judges B
of this Court. Reliance was placed by the appelll>llt on a recent two-judge
Bench decision of this Court in Dr. Suresh Gupta v. Govt. of NCT of Delhi
and Anr., (2004] 6 SCC 422. The Bench hearing this appeal doubted the
correctness of the view taken in Dr. Suresh Gupta's case and vide order dated
9.9.2004 expressed the opinion that the matter called for consideration by a
Bench of three Judges. This is how the case has come up for hearing before c
this Bench.

In Dr. Suresh Gupta's case, the patient, a young man with no history
of any heart ailment, was subjected to an operation performed by Dr. Suresh
Gupta for nasal deformity. The operation was neither complicated nor D
serious. The patient died. On investigation, the cause of death was found to
be "not introducing a cuffed endotracheal tube of proper size as to prevent
aspiration of blood from the wound in the respiratory passage". The Bench
formed an opinion that this act attributed to the doctor, even if accepted to
be true, could be described as an act of negligence as there was lack of due
care and precaution. But, the Court categorically held "for this act of
E
negligence he may be liable in tort, his carelessness or want of due attention
and skill cannot be described to be so reckless or grossly negligent as to make
him criminally liable".

The referring Bench in its order dated 9.9.2004 has assigned two F
reasons fortheir disagreement with the view taken in Dr. Suresh Gupta's case
which are as under:-

(I) Negligence or recklessness being 'gross' is not a requirement of Section
304A of !PC and if the view taken in Dr. Suresh Gupta's case is to be G
followed then the word 'gross' shall have to be read into Section 304A
!PC for fixing criminal liability on a doctor. Such an approach cannot
be countenanced.

(2) Different standards cannot be applied to doctors and others. In all cases H
316 SUPREME COURT REPORTS (2005] SUPP. 2 S.C.R.

A it has to be seen whether the impugned act was rash or negligent. By
carrying out a separate treatment for doctors by introducing degree of -
rashness or negligence, violence would be done to the plain and
unambiguous language of section 304A. If by adducing evidence it is
proved that there was no rashness or negligence involved, the trial court
B dealing with the matter shall d'ecide appropriately. But a doctor cannot
be placed at a different pedestal for finding out whether rashness or
negligence was involved.

We have heard the learned counsel for the appellant, the respondent-
State and the respondent complainant. As the question of medical negligence
C arose for consideration, we thought it fit to issue notice to Medical Council
of India to assist the Court at the time of hearing which it has done. In
addition, a registered society 'People for Better Treatment', Kolkata; Delhi
Medical Council, Delhi Medical Association and Indian Medical Association
sought for intervention at the hearing as the issue arising for decision is of
D vital significance for the medical profession. They too have been heard.
Mainly, the submissions made by the learned counsel for the parties and the
intervenors have centred around two issues : (i) Is there a difference in civil
and criminal law on the concept of negligence?; and (ii) whether a different
standard is applicable for recording a finding ofnegligence when a professional,
in particular, a doctor is to be held guilty of negligence?
E
With the awareness in the society and the people in general gathering
consciousness about their rights, actions for damages in tort are on the
increase. Not only civil suits are filed, the availability of a forum for
grievance redressal under the Consumer Protection Act, 1986 having
F jurisdiction to hear complaints against professionals for 'deficiency in
service', which expression is very widely defined in the Act, has given rise
to a large number of complaints against professionals, in particular against
doctors, being filed by the persons feeling aggrieved. Criminal complaints
are being filed against doctors alleging commission of offences punishable
under Section 304A or Sections 336/337/338 of the IPC alleging rashness
G or negligence on the part of the doctors resulting in loss of life or injury (of
varying degree) to the patient. The present one is such a case. The order of
reference has enabled us to examine the concept of 'negligence', in particular
'professional negligence', and as to when and how it does give rise to an
action under the criminal law. We propose to deal with the issues in the
H interests of settling the law.
JACOB MATHEW v. STA TE [LAHOTJ, CJ.] 317

Negligence as a tort A

The jurisprudential concept of negligence defies any precise definition.
Eminent jurists and leading judgments have assigned various meanings to
negligence. The concept as has been acceptable to Indian jurisprudential
thought is well-stated in the Law of Torts, Ratanlal & Dhirajlal (Twenty- B
fourth Edition 2002, edited by Justice G.P. Singh). It is stated (at p.441-442)
- "Negligence is the breach of a duty caused by the omission to do
something which a reasonable man, guided by those considerations which
ordinarily regulate the conduct of human affairs would do, or doing
something which a prudent and reasonable man would not do. Actionable
negligence consists in the neglect of the use of ordinary care or skill towards c
a person to whom the defendant owes the duty of observing ordinary care
and skill, by which neglect the plaintiff has suffered injury to his person or
property ............. The definition involves three constituents ofnegligence: (l)
A legal duty to exercise due care on the part of the party complained of
towards the party complaining the farmer's conduct within the scope of the D
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
necessary ingredient of this tort."

According to Charlesworth & Percy on Negligence (Tenth Edition,
2001), in current forensic speech, negligence has three meanings. They are: E
(i) a state of mind, in which it is opposed to intention; (ii) careless conduct;
and (iii) the breach of duty to take care that is imposed by either common
or statute law. All three meanings are applicable in different circumstances
but any one of them does not necessarily exclude the other meanings. (Para
1.0 l) The essential components of negligence, as recognized, are three: F
"duty", "breach" and "resulting damage", that is to say:-

l. the existence of a duty to take care, which is owed by the
defendant to the complainant;

2. the failure to attain that standard of care, prescribed by the law, G
thereby committing a breach of such duty; and

3. damage, which is both causally connected with such breach
and recognized by the law, has been suffered by the complainant.
• (Para l.23) H
318 SUPREME COURT REPORTS (2005] SUPP. 2 S.C.R.

A If the claimant satisfies the court on the evidence that these three ingredients
are made out, the defendant should be held liable in negligence. (Para 1.24)

Negligence - as a tort and as a crime

B The term 'negligence' is used for the purpose of fastening the defendant
with liability under the Civil Law and, at times, under the Criminal Law. It
is contended on behalf of the respondents that in both the jurisdictions,
negligence is negligence, and jurisprudentially no distinction can be drawn
between negligence under civil law and negligence under criminal law. The
submission so made cannot be countenanced inasmuch as it is based upon
c a total departure from the established terrain of thought running ever since
the beginning of the emergence of the concept ofnegligence upto the modem
times. Generally speaking, it is the amount of damages incurred which is
detem1inative of the extent of liability in tort; but in criminal law it is not
the amount of damages but the amount and degree of negligence that is
D determinative of liability. 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. The essential ingredient of mens rea cannot be
excluded from consideration when the charge in a criminal court consists of
criminal negligence. In R. v. Lawrence, (1981) l All ER 974 HL, Lord
Dip lock spoke in a Bench of five and the other Law Lords agreed with him.
E He reiterated his opinion in R. v. Caldwell, (1981) l All ER 961 HL and dealt
with the concept of recklessness as constituting mens rea in criminal law. His
Lordship warned against adopting the simplistic approach of treating all
problems of criminal liability as soluble by classifying the test of liability as
being "subjective" or "objective", and said "Recklessness on the part of the
F doer of an act does presuppose that there is something in the circumstances
that would have drawn the attention of an ordinary prudent individual to the
possibility that his act was capable of causing the kind of serious harmful
consequences that the section which creates the offence was intended to
prevent, and that the risk of those harmful consequences occurring was not
so slight that an ordinary prudent individual would feel justified in treating
G them as negligible. It is only when this is so that the doer of the act is acting
'recklessly' if, before doing the act, he either fails to give any thought to the
possibility of there being any such risk or, having recognized that there was
such risk, he nevertheless goes on to do it."

H The moral culpability of recklessness is not located in a desire to cause
JACOB MATHEW v. STA TE [LAHOTI, CJ.] 319

harm. It resides in the proximity of the reckless state of mind to the state of A
mind present when there is an intention to cause hann. There is, in other
words, a disregard for the possible consequences. The consequences entailed
in the risk may not be wanted, and indeed the actor may hope that they do
not occur, but this hope nevertheless fails to inhibit the taking of the risk.
Certain types of violation, called optimizing violations, may be motivated by B
thrill-seeking. These are clearly reckless.

In order to hold the existence of criminal rashness or criminal negligence
it shall have to be found out that the rashness was of such a degree as to
amount to taking a hazard knowing that the hazard was of such a degree that
injury was most likely imminent. The element of criminality is introduced
c
by the accused having run the risk of doing such an act with recklessness
and indifference to the consequences. Lord Atkin in his speech in Andrews
v. Director of Public Prosecutions, [1937] A.C. 576, stated, "Simple lack of
care - such as will constitute civil liability is not enough; for purposes of the
criminal law there are degrees of negligence; and a very high degree of D
negligence is required to be proved before the felony is established." Thus,
a clear distinction exists between "simple lack of care" incurring civil liability
and "very high degree of negligence" which is required in criminal cases.
In Riddell v. Reid, (1943] A.C. 1 (at 31), Lord Porter said in his speech-
"A higher degree of negligence has always been demanded in order k> E
establish a criminal offence than is sufficient to create civil liability."
(Charlesworth & Percy, ibid, Para 1.13)

The fore-quoted statement of law in Andrews has been noted with
approval by this Court in Syad Akbar v. State of Karnataka, [1980] 1 SCC
F
30. The Supreme Court has dealt with and pointed out with reasons the
distinction between negligence in civil law and in criminal law. Their
Lordships have opined that there is a marked difference as to the effect of
evidence, viz. the proof, in civil and criminal 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 G
proceedings, the persuasion of guilt must amount to such a moral certainty
as convinces the mind of the Court, as a reasonable man, beyond all
reasonable doubt. Where negligence is an essential ingredient of the offence,
the negligence to be established by the prosecution must be culpable or gross
' and not the negligence merely based upon an error of judgment. H
320 SUPREME COURT REPORTS [2005] SUPP. 2 S.C.R.

A Law laid down by Straight, J. in the case Reg v. !du Beg, [1881] 3 All.
776, has been held good in cases and noticed in Bhalchandra Waman Pathe
v. State ofMaharashtra, (1968) Mh.L.J. 423 - a three-Judge Bench decision
of this Court. It has been held that while negligence is an omission to do
something which a reasonable man, guided upon those considerations which
ordinarily regulate the conduct of human affairs, would do, or doing
B
something which a prudent and reasonable man would not do; criminal
negligence is the gross and culpable neglect or failure to exercise that
reasonable and proper care and precaution to guard against injury either to
the public generally or to an individual in particular, which having regard
to all the circumstances out of which the charge has arisen, it was the
c imperative duty of the accused person to have adopted.

In our opinion, the factor of grossness or degree does assume significance
while drawing distinction in negligence actionable in tort and negligence
punishable as a crime. To be latter, the negligence has to be gross or of a
·D .¥ery high degree.

Negligence by professionals

In the law of negligence, professionals such as lawyers, doctors,
architects and others are included in the category of persons professing some
E special skill or skilled persons generally. Any task which is required to be
performed with a special skill would generally be admitted or undertaken to
be performed only if the person possesses the requisite skill for performing
that task. Any reasonable man entering into a profession which requires a
particular level of learning to be called a professional of that branch,
F impliedly assures the person dealing with him that the skill which he
professes to possess shall be exercised and exercised with reasonable degree
of care and caution. He does not assure his client of the result. A lawyer does
not tell his client that the client shall win the case in all circumstances. A
physician would not assure the patient of full recovery in every case. A
surgeon cannot and does not guarantee that the result of surgery would
G invariably be beneficial, much less to the extent of I 00% for the person
operated on. The only assurance which such a professional can give or can
be understood to have given by implication is that he is possessed of the
requisite skill in that branch of profession which he is practising and while
undertaking the performance of the task entrusted to him he would be
H exercising his skill with reasonable competence. This is all what the person
JACOB MATHEW v. STATE (LAHOTJ, CJ.] 321

approaching the professional can expect. Judged by this standard, a professional A
may be held liable for negligence on one of two findings: either 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 he did possess. The standard to be applied for judging, whether the
person charged has been negligent or not, would be that of an ordinary B
competent person exercising ordinary skill in that profession. It is not
necessary for every professional to possess the highest level of expe~ise in
that branch which he practices. In Michael Hyde and Associates v. J.D.
Williams & Co. Ltd., [2001] P.N.L.R. 233, CA, Sedley L.J. said that where
a profession embraces a range of views as to what is an acceptable standard
of conduct, the competence of the defendant is to be judged by the lowest c
standard that would be regarded as acceptable. (Charlesworth & Percy,. ibid,
Para 8.03)

Oft' quoted passage defining negligence by professionals, generally and
not necessarily confined to doctors, is to be found in the opinion of McNair D
J. in Bo/am v. Friern Hospital Management Committee, [1957] l W.L.R. 582,
586 in the following words:

"Where you get a situation which involv.es 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 )he man on the top of a Clapham E
omnibus, because he has not got this special skill. The test is the
standard of the ordinary skilled man exercising and professing to
have that special skill ... A man need not possess the highest expert
skill; it is well established law that it is sufficient ifhe exercises the
ordinary skill of an ordinary competent man exercising that particular F
art." (Charlesworth & Percy, ibid, Para 8.02)

The water of Bo/am test has ever since flown and passed under several
bridges, having been cited and dealt with in several judicial pronouncements,
one after the other and has continued to be well received by every shore it
has touched as neat, clean and well-condensed one. After a review of various G
authorities Bingham L.J. in his speech in Eckersley v. Binnie, [1988] 18 Con.
L.R. l, 79 summarised the Bo/am test in the following words:-

"From these general statements it follows that a professional
man should command the corpus of knowledge which forms part H
322 SUPREME COURT REPORTS [2005] SUPP. 2 S.C.R.

A of the professional equipment of the ordinary member of his
profession. He should not lag behind other ordinary assiduous and
intelligent members of his profession in knowledge of new advances,
discoveries and developments in his field. He should have such an
awareness as an ordinarily competent practitioner would have of the
deficiencies in his knowledge and the limitations on his skill. He
B
should be alert to the hazards and risks in any professional task he
undertakes to the extent that other ordinarily competent members ·of
the profession would be alert. He must bring to any professional task
he undertakes no less expertise, skill and care than other ordinarily
competent members of his profession would bring, but need bring
c no more. The standard is that of the reasonable average. The law
does not require of a professional man that he be a paragon
combining the qualities of polymath and prophet." (Charlesworth &
Percy, ibid, Para 8.04)

.The degree of skill and care required by a medical practitioner is so
stated in Halsbury's Laws of England (Fourth Edition, Vol.30, Para 35):-

"The practitioner must bring to his task a reasonable degree of
skill and knowledge, and must exercise a reasonable degree of care.
Neither the very highest nor a very low degree of care and
E competence, judged in the light_ of the particular Fircumstances of
each case, is what the law requires, and a perso'n is not liable in
negligence because someone else of greater skill and knowledge
would have prescribed different treatment or operated in a different
way; nor is he guilty of negligence if he has acted in accordance
F with a practice accepted as proper by a responsible body adverse
opinion also existed among medical men.

Deviation from normal practice is not necessarily evidence of
negligence. To establish liability on that basis it must be shown (1)
that there is a usual and normal practice; (2) that the defendant has
G not adopted it; and (3) that the course in fact adopted is one no
professional man of ordinary skill would have taken had he been
acting with ordinary care."

Abovesaid three tests have also been stated as determinative of negligence
H in professional practice by Charlesworth & Percy in their celebrated work
JACOB MATHEW v. STATE (LAHOTI, CJ.] 323

on Negligence (ibid, para 8.110) A

In the opinion of Lord Denning, as expressed in Hucks v. Cole, [1968]
Il8 New LJ 469, a medical practitioner was not to be held liable simply
because things went wrong from mischance or misadventure or through an
error of judgment in choosing one reasonable course of treatment in B
preference of another. A medical practitioner would be liable only where his
conduct fell below that of the standards of a reasonably competent practitioner
in his field.

The decision of House of Lords in Maynardv. West Midlands Regional
Health Authority, [1985] l All ER 635 HL by a Bench consisting of five Law c
Lords has been accepted as having settled the law on the point by holding
that it is not enough to show that there is a body of competent professional
opinion which considers that decision of the defendant professional was a
wrong decision, if there also exists a body of professional opinion, equally
competent, which supports the decision as reasonable in the circumstances. D
It is not enough to show that subsequent events show that the operation need
never have been performed, if at the time the decision to operate was taken,
it was reasonable, in the sense that a responsible body of medical opinion
would have accepted it as proper. Lord Scarman who recorded the leading
speech with which other four Lords agreed quoted the following words of
Lord President (Clyde) in Hunter v. Hanley, (!955) SLT 213 at 217, E
observing that the words cannot be bettered - "In th'e realm of diagnosis
and treatment there is ample scope for genuine difference of opinion and one
man clearly is not negligent merely because his conclusion differs from that
of other professional men ... The true test for establishing negligence in
diagnosis or treatment on the part of a doctor is whether he has been proved F
to be guilty of such failure as no doctor of ordinary skill would be guilty of
if acting with ordinary care ...". Lord Scarman added - "a doctor who
professes to exercise a special skill must exercise the ordina. y skill of his
speciality. Differences of opinion and practice exist, and will always exist,
in the medical as in other professions. There is seldom any one answer
exclusive of all others to problems of professional judgment. A court may G
prefer one body of opinion to the other, but that is no basis for a conclusion
of negligence." His Lordship further added "that a judge's 'preference' for
one body of distinguished professional opinion to another also professionally
distinguished is not sufficient to establish negligence in a practitioner whose
actions ·have received the seal of approval of those whose opinions, truthfully H
324 SUPREME COURT REPORTS [2005] SUPP. 2 S.C.R.

A expressed, honestly held, were not preferred."

The classical statement oflaw in Bo/am 's case has been widely accepted
as decisive of the standard of care required both of professional men
generally and medical practitioners in particular. It has been invariably cited
with approval before Courts in India and applied to a:;; touchstone to test the
B pleas of medical negligence. In tort, it is ~nough for the defendant to show
that the standard of care and the skill attained was that of the ordinary
competent medical practitioner exercising an ordinary degree of professional
skill. The fact that a defendant charged with negligence acted in accord with
the general and approved practice is enough to clear him of the charge. Two
c things are pertinent to be noted. Firstly, the standard of care, when assessing
the practice as adopted, is judged in the light of knowledge available at the
time (of the incident), and not at the date of trial. Secondly, when the charge
of negligence arises out of failure to use some particular equipment, the
charge would fail if the equipment was not generally available at that point
of time on which it is suggested as should have been used.
D
A mere deviation from normal professional practice is not necessarily
evidence of negligence. Let it also be noted that a mere accident is not
evidence of negligence. So also an error of judgment on the part of a
professional is not negligence per se. Higher the acuteness in emergency and
E higher the complication, more are the chances of error of judgment. At times,
the professional is confronted with making a choice between the devil and
the deep sea and he has to choose the lesser evil. The medical professional
is often called upon to adopt a procedure which involves higher element of
risk, but which he honestly believes as providing greater chances of success
for the patient rather than a procedure involving lesser risk but higher chances
F of failure. Which course is more appropriate to follow, would depend on the
facts and circumstances of a given case. The usual practice prevalent
nowadays is to obtain the consent of the patient or of the person incharge
of the patient if the patient is not be in a position to give consent before
adopting a given ·procedure. So long as it can be found that the procedure
G which was in fact adopted was one which was acceptable to medical science
as on that date, the medical practitioner cannot be held negligent merely
because he chose to follow one procedure and not another and the result was
a failure.

No sensible professional would intentionally commit an act or omission
H which would result in loss or injury to the patient as the professional
JACOB MATHEW v. STATE [LAHOTI, CJ.] 325

reputation of the person is at stake. A single failure may cost him dear in A
his career. Even in civil jurisdiction, the rule of res ipsa loquitur is not of
universal application and has to be applied with extreme care and caution to
the cases of professional negligence and in particular that of the doctors. Else
it would be counter productive. Simply because a patient has not favourably
responded to a treatment given by a physician or a surgery has failed, the B
doctor cannot be held liable per se by applying the doctrine of res ipsa
loquitur.

Res ipsa loquitur is a rule of evidence which in reality belongs to the
law of torts. Inference as to negligence may be drawn from proved
circumstances by applying the rule if the cause of the accident is unknown c
and no reasonable explanation as to the cause is coming forth from the
defendant. In criminal proceedings, the burden of proving negligence as an
essential ingredient of the offence lies on the prosecution. Such ingredient
cannot be said to have been proved or made out by resorting to the said rule
(See Syad Akbar v. State of Karnataka, [1980] I SCC 30). Incidentally, it
may be noted that in Krishnan and A nr. v. State of Kera/a, [ 1996] l 0 SCC D
508 the Court has observed that there may be a case where the proved facts
would themselves speak of sharing of common intention and while making
such observation one of the learned judg~s constituting the Bench has in his
concurring opinion merely stated "res ipsa loquitur'. Nowhere it has been
stated that the tule has applicability in a criminal case and an inference as E
to an essential ingredient of an offence can be found proved by resorting to
the said rule. In our opinion, a case under Section 304A !PC cannot be
decided solely by applying the rule of res ipsa loquitur.

A medical practitioner faced with an emergency ordinarily tries his best
to redeen1 the patient out of his suffering. He does not gain anything by acting F
with negligence or by omitting to do an act. Obviously, therefore, it will be
for the complainant to clearly make out a case of negligence before a medical
practitioner is charged with or proceeded against criminally. A surgeon with
shaky hands under fear of legal action cannot perform a successful operation
and a quivering physician cannot admini~ter the end-dose of medicine to his
patient.
G

If the hands be trembling with the dangling fear of facing a criminal
prosecution in the event of failure for whatever reason -whether attributable
to himself or not, neither a surgeon can successfully wield his life-saving
scalper to perform an essential surgery, nor can a physician successfully H
326 SUPREME COURT REPORTS [2005] SUPP. 2 S.C.R.

A administer the life-saving dose of medicine. Discretion being better part of
valour, a medical professional would feel better advised to leave a terminal
patient to his own fate in the case of emergency where the chance of success
may be I 0% (or so), rather than taking the risk of making a last ditch effort
towards saving the subject and facing a criminal prosecution if his effort fails.
B Such timidity forced upon a doctor would be a disservice to the society.

The purpose of holding a professional liable for his act or omission, if
negligent, is to make the life safer and to eliminate the possibility of
recurrence of negligence in future. Human body and medical science - both
are too complex to be easily understood. To hold in favour of existence of
C negligence, associated with the action or inaction of a medical professional,
requires an in-depth understanding of the working of a professional as also
the nature of the job and of errors committed by chance, which do not
necessarily involve the element of culpability.

The subject ofnegligence in the context of medical profession necessarily
D calls for treatment with a difference. Several relevant considerations in this
regard are found mentioned by Alan Merry and Alexander McCall Smith in
their work "Errors, Medicine and the Law" (Cambridge University Press,
200 I). There is a marked tendency to look for a human actor to blame for
an untoward event - a tendency which is closely linked with the desire to
E punish. Things have gone wrong and, therefore, somebody must be found
to answer for it. To draw a distinction between the blameworthy and the
blameless, the notion of mens rea has to be elaborately understood. An .
empirical study would reveal that the background to a mishap is frequently
far more complex than may generally be assumed. It can be demonstrated
that actual blame for the outcome has' to be attributed with great caution. For
F a medical accident or failure, the responsibility may lie with the medical
practitioner and equally it may not. The inadequacies of the system, the
specific circumstances of the case, the nature of human psychology itself and
sheer chance may have combined to produce a result in which the doctor's
contribution is either relatively or completely blameless. Human body and
G its working is nothing less than a highly complex machine. Coupled with the
complexities of medical science, the scope for misimpressions, misgivings
and misplaced allegations against the operator i.e. the doctor, cannot be ruled
out. One may have notions of best or ideal practice which are different from
the reaHty of how medical practice is carried on or how in real life the doctor·
functions. The factors of pressing need and limited resources cannot be ruled
H
JACOB MATHEW v. STATE [LAHOTI, CJ.] 327

out from consideration. Dealing with a case of medical negligence needs a A
deeper understanding of the practical side of medicine.

At least three weighty considerations can be pointed out which any
forum trying the issue of medical negligence in any jurisdiction must keep
in mind. These are: (i) that legal and disciplinary procedures should be
properly founded on firm, moral and scientific grounds; (ii) that patients will
B
be better served if the real causes of harm are properly identified and
appropriately acted upon; and (iii) that many incidents involve a contribution
from more than one person, and the tendency is to blame the last identifiable
element in the chain of causation the person holding the 'smoking gun'.
c
Accident during the course of medical or surgical treatment has a wider
meaning. Ordinarily, an accident n1eans an unintended and unforeseen
injurious occurrence; something that does not occur in the usual course of
events or that could not be reasonably anticipated (See, Black's Law
Dictionary, 7th Edition). Care has to be taken to see that the result of an
accident which is exculpatory may not persuade the human mind to confuse D
it with the consequence of negligence.

Medical Professionals in Crinzina/ LG"l-1/

The criminal law has invariably placed the medical professionals on a E
pedestal different from ordinary mortals. The Indian Penal Code enacted as
far back as in the year 1860 sets out a few vocal examples. Section 88 in
the Chapter on General Exceptions provides exemption for acts not intended
to cause death, done by consent in good faith for person's benefit. Section
92 provides for exemption for acts done in good faith for the benefit of a
person without his consent though the acts cause harm to a person and that F
person has not consented to suffer such harm. There are four exceptions listed
in the Section which is not necessary in this context to deal with. Section 93
saves from criminality certain communications made in good faith. To these
provisions are appended the following illustrations:-

Section 88
G

A, a surgeon, knowing that a particular operation is likely to cause
the death of Z, who suffers under a painful complaint, but not
intending to cause Z's death and intending in good faith, Z's benefit,
performs that operation on Z, with Z's consent. A has committed H
328 SUPREME COURT REPORTS [2005] SUPP. 2 S.C.R.

A no offence.

Section 92
,.
Z is thrown from his horse, and is insensible. A, a surgeon, finds
that Z requires to be trepanned. A, not intending Z's death, but in -
B good faith, for Z's benefit, performs the trepan before Z recovers
his power of judging for himself. A has committed no offence.

A, a surgeon, sees a child suffer an accident which is likely to
prove fatal unless an operation be immediately performed. There is
c no time to apply to the child's guardian. A performs the operation
inspite of the entreaties of the child, intending, in good faith, the
child's benefit. A has committed no offence.

Section 93

D A, a surgeon, in goocl faith, communicates to a patient his opinion
that he cannot live. The patient dies in consequence of the shock.
A has committed no offence, though he knew it to be likely that the
communication might cause the patient's death.

It is interesting to note what Lord Macaulay had himself to say about
E Indian Penal Code. We are inclined to quote a few excerpts from his speech
to the extent relevant for our purpose from "Speeches and Poems with the
Report and Notes on the Indian Penal Code" by Lord Macaulay (Houghton,
Mifflin and Company, published in 1874).

F "Under the provisions of our Code, this case would be very
differently dealt with according to circumstances. If A. kills Z. by
administering abortives to her, with the knowledge that those
abortives are likely to cause her death, he is guilty of voluntary
culpable homicide, which will be voluntary culpable homicide by
consent, if Z. agreed to run the risk, and murder if Z. did not so
G agree. If A causes miscarriage to Z., not intending to cause Z.'s
death, nor thinking it likely that he shall cause Z.'s death, but so
rashly or negligently as to cause her death, A. is guilty of culpable
homicide not voluntary, and will be liable to the punishment
provided for tlie causing of miscarriage, increased by imprisonment
H for a term not exceeding two years. Lastly, if A took such
JACOB MATHEW v. STATE [LAHOTI, CJ.) 329

precautions that there was no reasonable probability that Z. 's death A
would be caused, and ifthe medicine were rendered deadly by some
accident which no human sagacity could have foreseen, or by some
peculiarity in Z.' s constitution such as there was no ground whatever
to expect, A. will be liable to no punishment whatever on account
of her death, but will of course be liable to the punishment provided B
for causing miscarriage.

It may be proper for us to offer some arguments in defence of this
part of the Code.

It will be admitted that when an act is in itself innocent, to punish C
the person who does it because bad consequences, which no human
wisdom could have foreseen, have followed from it, would be in the
highest degree barbarous and absurd." (P.419)

HTo punish as a murderer every man who, while committing a
heinous offence, causes death by pure misadventure, is a course D
which evidently adds nothing to the security of human life. No man
can so conduct himself as to make it absolutely certain that he shall
not be so unfortunate as to cause the death of a fellow-creature. The
utmost that he can do is to abstain from everything which is at all
likely to cause death. No fear of punishment can make him do more E
than this; and therefore, to punish a man who has done this can add
nothing to the security of human life. The only good effect which
such punishment can produce will be to deter people from committing
any of those offences which tum into murders what are in themselves
mere accidents. It is in fact an addition to the punishment of those
offences, and it is an addition made in the very worst way." (p.421) F
"When a person engaged in the commission of an offence causes
death by rashness or negligence, but without either intending to
cause death, or thinking it likely that he shall cause death, we
propose that he shall be liable to the punishment of the offence
G
which he was engaged in committing, superadded to the ordinary
punishment of involuntary culpable homicide.

The arguments and illustrations which we have employed for the
purpose of showing that the involuntary causing of death, without
either rashness or negligence, ought, under no circumstances, to be H
330 SUPREME COURT REPORTS [2005) SUPP. 2 S.C.R.

A punished at all, will, with some modifications, which will readily
suggest themselves, serve to show that the involuntary causing of
death by rashness or negligence, though always punishable, ought,
under no circumstances to be punished as murder." (P.422)

The following statement of law on criminal negligence by reference to
B surgeons, doctors etc. and unskillful treatment contained in Roscoe's law of
Evidence (Fifteenth Edition) is classic:

"Where a person, acting as a medical man, &c., whether licensed
or unlicensed, is so negligent in his treatment of a patient that death
c results, it is manslaughter ifthe negligence was so great as to amount
to a crime, and whether or not there was such a degree of negligence
is a question in each case for the jury. "In explaining to juries the
test which they should apply to determine whether the negligence
in the particular case amounted or did not amount to a crime, judges
have used many epithets, such as 'culpable,' 'criminal', 'gross',
D 'wicked', 'clear', 'complete.' But whatever epithet be used and
whether an epithet be used or not, in order to establish criminal
liability the facts must be such that, in the opinion of the jury, the
negligence of the accused went beyond a mere matter of compensation
between subjects and showed such disregard for the life and safety
E of others as to amount to a crime against the State and conduct
deserving punishment." (p. 848-849)

xxx xxx xxx

"whether he be licensed or unlicensed, ifhe display gross ignorance,
or gross inattention, or gross rashness, in his treatment, he is
F
criminally responsible. Where a person who, though not educated
as an accoucheur, had been in the habit of acting as a man-midwife,
and had unskilfully treated a woman who died in childbirth, was
indicted for the murder, L. Ellenborough said that there was no
evidence of murder, but the jury might convict of man-slaughter.
G "To substantiate that charge the prisoner must have been guilty of
criminal misconduct, arising either from the grossest ignorance or
the [most?] criminal inattention. One or other of these is necessary
to make him guilty of that criminal negligence and misconduct
which is essential to make out a case of manslaughter."
(p.849)
H
JACOB MATHEW v. STATE [J.,AHOTI, CJ.] 331

. A review of Indian decisions on criminal negligence A
We are inclined to, and we must - as duty bound, take note of some
of the relevant decisions of the Privy Council and of this Court. We would
like to preface this discussion with the law laid down by the Privy Council
in John Oni Akerele v. The King, AIR ( 1943) PC 72. A duly qualified medical
practitioner gave to his patient the injection of Sobita which consisted of
B
sodium bismuth tartrate as given in the British Pharmacopoea. However, what
was administered was an overdose of Sobita. The patient died. The doctor
was accused of manslaughter, reckless and negligent act. He was convicted .
•
The matter reached in appeal before the House of Lords. Their Lordships
quashed the conviction. On a review of judicial opinion and an illuminating C
discussion on the points which are also relevant before us, what their
Lordships have held can be summed up as under:-

(i) That a doctor is not criminally responsible for a patient's death
unless his negligence or incompetence went beyond a mere matter
of compensation between subjects and showed such disregard for D
life and safety of others as to amouht to a crime against the State.;

(ii) That (he· degree of negligence required is that it should be
gross, and that neither a jury nor a court can transform negligence
of a lesser degree into gross negligence merely by giving it that E
appellation. ........... There is a difference in kind between the
negligence which gives ~.right to compensation and the negligence
which is a crime.

{iii) It is impossible to define culpable or criminal negligence, and
it is not possible to make the distinction between actionable F
negligence and criminal negligence intelligible, except by means of
illustrations drawn from actual judicial opinion. ..... The most
favourable view of the conduct of an accused medical man has to
be taken,/or it would be most fatal to the efficiency of the medical
profession if no one could administer medicine without a halter
,.,,, round his neck " G
(emphasis supplied)

•Their Lordships refused to accept the view that criminal negligence was
proved merely because a number of persons were made gravely ill after
1 receiving an injection of Sobita from the appellant coupled with a finding H
332 SUPREME COURT REPORTS [2005] SUPP. 2 S.C.R.

A that a high degree of care was not exercised. Their Lordships also refused
· to agree with the thought that merely because too strong a mixture was
dispensed once and a number of persons were made gravely ill, a criminal
degree of negligence was proved.

B The question of degree has always been considered as relevant to a
distinction between negligence in civil law and negligence in criminal law.
In Kurban Hussein Mohamedalli Rangawalla v. State of Maharashtra,
[1965] 2 SCR 622, while dealing with Section 304A of IPC, the following
statement of law by Sir Lawrence Jenkins in Emperor v. Omkar Rampratap .
4 Born LR 679, was cited with approval:-
c
"To impose criminal liability under Section 304-A, Indian Penal
Code, it is necessary that the death should have been the direct result
of a rash and negligent act of the accused, and that act must be the
proximate and efficient cause without the intervention of another's
D negligence. It must be the causa causans; it is not enough that it may
have been the causa sine qua non. "

K.N. Wanchoo, J. (as he then was), speaking for the Court, observed
that the abovesaid view of the law has been generally followed by High
Courts in India and was the correct view to take of the meaning of Section
E 304A. The same view has been reiterated in Kishan Chand & Anr. v. The
State of Haryana, [1970] 3 SCC 904.

In Juggankhan v. The State of Madhya Pradesh, [1965] 1 SCR 14, the
accused, a registered Homoeopath, administered 24 drops of stramonium and
F a leaf of dhatura to the patient suffering from guinea worm. The accused had
not studied the effect of such substances being administered to a human
being. The poisonous contents of the leaf of dhatura, were not satisfactorily
established by the prosecution. This Court exonerated the accused of the
charge under Section 302 IPC. However, on a finding that stramonium and
dhatura leaves are poisonous and in no system of medicine, except perhaps
G Ayurvedic system, the dhatura leaf is given as cure for guinea worm, the act
of the accused who prescribed poisonous material without studying their
probable effect was held to be a rash and negligent act. It would be seen that
the profession of a Homoeopath which the accused claimed to profess did
not permit use of the substance administered to the patient. The accused had
H . no knowledge of the effect of such substance being administered and yet he
JACOB MATHEW v. STATE [LAHOTI, CJ.] 333

did so. In this background, the inference of the accused being guilty of rash A
and negligent act was drawn against him. In our opinion, the principle which
emerges is that a doctor who administers a medicine known to or used in
a particular branch of medical profession impliedly declares that he has
knowledge of that branch of science and if he does not, in fact, possess that
knowledge, he is prima facie acting with rashness or negligence.
B
Dr. Laxman Balkrishna Joshi v. Dr. Trimbak Bapu Godbo/e and Anr.,
[1969] I SCR 206 was a case under Fatal Accidents Act, I 855. It does not
make a reference to any other decided ca:;e. The duties which a doctor owes
to his patients came up for consirleration. The Court held that a person who
holds himself out ready to give medical advice and treatment impliedly C
undertakes that he is possessed of skill and knowledge for that purpose. Such
a person when consulted by a patient owes him certain duties, viz., a duty
of care in deciding whether to undertake the case, a duty of care in deciding
what treatment to be given or a duty of care in the administration of that
treatment. A breach of any of those duties gives a right of action for D
negligence to the patient. The practitioner must bring to his task a reasonable
degree of skill and knowledge and must exercise a reasonable degree of care.
Neither the very highest nor a very low degree of care and competence judged
in the light of the particular circumstances of each case is what the law
requires. The doctor no doubt has a discretion in choosing treattnent '"lhich
he proposes to give to the patient and such discretion is relatively ampler in E
cases of e1nergency. In this case, the death of patient was caused due to shock
resulting from reduction of the fracture attempted by doctor without taking
the elementary caution of giving anaesthetic to the patient. The doctor was
held guilty of negligence and liability for damages in civil law. We hasten
to add that criminal negligence or liability under criminal law was not an issue F
before the Court - as it did not arise and hence was not considered.

In the year I 996, there are 3 reported decisions available. Indian
Medical Association v. V.P. Shantha and Ors., [I 995] 6 SCC 651 is a three-
, Judge Bench decision. The principal issue which arose for decision by the
Court was whether a medical practitioner renders 'service' and can be G
proceeded against for 'deficiency in service' before a forum under the
Consumer Protection Act, 1986. The Court dealt with how a 'profession'
differs from an 'occupation' especially in the context of performance of
duties and hence the occumnce of negligence. The Court noticed that
medical professionals do not enjoy any immunity from being sued in contract H
334 SUPREME COURT REPORTS [2005] SUPP. 2 S.C.R.

A or tort (i.e. in civil jurisdiction) on the ground of negligence. However, in
the observation made in the context of determining professional liability as
distinguished from occupational liability, the Court has referred to authorities,
in particular, Jackson & Powell and have so stated the principles, partly
quoted from the authorities :-
B
"In the matter of professional liability professions differ from
occupations for the reason that professions operate in spheres where
success cannot be achieved in every case and very often success or
failure depends upon factors beyond the professional man's control.
In devising a rational approach to professional liability which must
c provide proper protection to the consumer while allowing for the
factors mentioned above, the approach of the Courts is to require
that professional men should possess a certain minimum degree of
competence and that they should exercise reasonable care in the
discharge of their duties. In general, a professional man owes to his
client a duty in tort as well as in contract to exercise reasonable care
D
in giving advice or performing services. (See : Jackson & Powell
on Professional Negligence, 3rd Edn., paras 1-04, 1-05, and 1-56)."

In Poonam Verma v. Ashwin Patel and Ors., [1996] 4 SCC 332 a doctor
registered as medical practitioner and entitled to practice in Homoeopathy
E only, prescribed an allopathic medicine to the patient. The patient died. The
doctor was held to be negligent and liable to compensate the wife of the
deceased for the death of her husband on the ground that the doctor who was
entitled to practice in homoeopathy only, was under a statutory duty not to
enter the field of any other system of medicine and since he trespassed into
a prohibited field and prescribed the allopathic medicine to the patient
F causing the death, his conduct amounted to negligence per se actionable in
civil law. Dr. Laxman Balkrishna Joshi's case (supra) was followed. Vide
para 16, the test for determining whether there was negligence on the part
of a medical practitioner as laid down in Bo/am 's case (supra) was cited and
approved.
G
In Achutrao Haribhau Khodwa and Ors. v. State of Maharashtra and
Ors., [1996] 2 SCC 634 the Court noticed that in the very nature of medical
profession, skills differs from doctor to doctor and more than one alternative
course of treatment are availabk, all admissible. Negligence cannot be
attributed to a doctor so long as he is performing his duties to the uest of
H
JACOB MATHEW v. STATE [LAHOTI, CJ.] 335

his ability and with due care and caution. Merely because the doctor chooses A
one course of action in preference to the other one available, he wquld not
be liable if the course of action chosen by him was acceptable to the medical
profession. It was a case where a mop was left inside the lady patient's
• abdomen during an operation. Peritonitis developed which led to a second
surgery being perfonned on her, but she could not survive. Liability for
B
negligence was fastened on the surgeon because no valid explanation was
forthcoming for the mop having been left inside the abdomen of the lady.
The doctrine of res ipsa /oquitur was held applicable 'in a case like this'.

Mis Spring Meadows Hospital and Anr. v. Harjo! Ahluwalia through
K.S. Ahluwalia and Anr., (1998] 4 SCC 39 is again a case of liability for c
negligence by a medical professional in civil· Jaw. It was held that an error
of judgment is not necessarily negligence. The Court referred to the decision
~
in Whitehouse & Jorden, [1981] I ALL ER 267, and cited with approval the
following statement of law contained in the opinion of Lord Fraser detennining
when an error of judgment can be tenned as negligence:-
D
"The true position is that an error of judgment may, or may not, be
negligent, it depends on the nature of the error. If it is one that would
not have been made by a reasonably competent professional man
professing to have the standard and type of skill that the defendant
holds himself out as having, and acting with ordinary care, then it E
is negligence. If, on the other hand, it is an error that such a man,
acting \Vith ordinary care, might have made, then it is not negligence."

In State of Haryana and Ors. v. Smt. Santra, [2000] 5 SCC 182 also
Bo/am 's test has been approved. This case too refers to liability for F
compensation under civil law for failure of sterilisation operation perfonned
by a surgeon. We are not dealing with that situation in the case before us
and, therefore, leave it to be dealt within an appropriate case.

Before we embark upon summing up our conclusions on the several
issues of law which we have dealt with hereinabove, we are inclined to quote G
some of the conclusions arrived at by the learned authors of "Errors,
Medicine and the Law" (pp. 241-248), (recorded at the end of the book in
the chapter titled 'Conclusion') highlighting the link between moral fault,
blame and justice in reference to medical profession and negligence. These
are of significance and relevant to the issues before us. Hence we quote :-
- H
336 SUPREME COURT REPORTS [2005] SUPP. 2 S.C.R.

A (i) The social efficacy of blame and related sanctions in particular cases
of deliberate wrongdoings may be a matter of ·dispute, but their
necessity - in principle - from a moral point of vie'Y, has been
accepted. Distasteful as punishment may be, the social, and possibly
moral, need to punish people for wrongdoing, occasionally in a severe
fashion, cannot be escaped. A society in which blame is overemphasized
B
may become paralysed. This is not only because such a society will
inevitably be backward-looking, but also because fear of blame inhibits
the uncluttered exercise of judgment in relations between persons. lfwe
are constantly concerned about whether our actions will be the subject
of complaint, and that such complaint is likely to lead to legal action t

c or disciplinary proceedings, a relationship of suspicious formality
between persons is inevitable. (ibid, pp. 242-243)

(ii) Culpability may attach to the consequence of an error in circumstances
,.
where substandard antecedent conduct has been deliberate, and has
D contributed to the generation of the error or to its outcome. In case of
errors, the only failure is a failure defined in terms of the normative
standard of what should have been done. There is a tendency to confuse
the reasonable person with the error-free person. While nobody can
avoid errors on the basis of simply choosing not to make them, people
can choose not to commit violations. A violation is culpable. (ibid, p.
E 245).

(iii) Before the court faced with deciding the cases of professional negligence
there are t\v..o sets of interests which are at stake : the interests of the
plaintiff and the interests of the defendant. A correct balance of these
F two sets of interests should ensure that tort liability is restricted to those
cases where there is a real failure to behave as a reasonably competent
practitioner would have behaved. An inappropriate raising of the
standard of care threatens this balance. (ibid, p.246). A consequence of
encouraging litigation for loss is to persuade the public that all loss
encountered in a medical context is the result of the failure of somebody
G in the system to provide the level of care to which the patient is entitled.
The effect of this on the doctor-patient relationship is distorting and will
not be to the benefit of the patient in the long run. It is also unjustified
to impose on those engaged in medical treatment an undue degree of
additional stress and anxiety in the conduct of their profession. Equally,
it would be wrong to impose such stress and anxiety on any other person ,~
H
JACOB MATHEW v. STATE (LAHOTI, CJ.] 337

performing a demanding function in society. (ibid, p.247). While A
expectations from the professionals must be realistic and the expected
standards attainable, this implies recognition of the nature of ordinary
human error and human limitations in the performance of complex
tasks. (ibid, p. 247).

(iv) Conviction for any substantial criminal offence requires that the
B
accused person should have acted with a morally blameworthy state of
mind. Recklessness and deliberate wrongdoing, are morally blameworthy,
but any conduct falling short of that should not be the subject of criminal
liability. Common-law systems have traditionally only made negligence
the subject of criminal sanction when the level of negligence has been c
high - a standard traditionally described as gross negligence. In fact,
negligence at that level is likely to be indistinguishable from recklessness.
(ibid, p.248).

(v) Blame is a powerful weapon. Its inappropriate use distorts tolerant and
constructive relations between people. Distinguishing between (a) D
accidents which are life's misfortune for which nobody is morally
responsible, (b) wrongs amounting to culpable conduct and constituting
grounds for compensation, and (c) those (i.e. wrongs) calling for
punishment on account of being gross or of a very high degree requires
and calls for careful, morally sensitive and scientifically informed E
analysis; else there would be injustice to the larger interest of the
society. (ibid, p. 248).

Indiscriminate prosecution of medical professionals for criminal negligence
is counter-productive and does no service or good to the society.
F
Conclusions summed up

We sum up our conclusions as under:-

(l) Negligence is the breach of a duty caused by omission to do something
which a reasonable man guided by those considerations which ordinarily G
regulate the conduct of human affairs would do, or doing something
which a prudent and reasonable man would not do. The definition of
negligence as given in Law of Torts, Ratanlal & Dhirajlal (edited by
Justice G.P. Singh), referred to hereinabove, holds good. Negligence
becomes actionable on account of injury resuliing from the act or H
338 SUPREME COURT REPORTS [2005] SUPP. 2 S.C.R.

A omission amounting to negligence attributable to the person sued. The
essential components of negligence are three: 'duty', 'breach' and
'resulting damage'.

(2) Negligence in the context of medical profession necessarily calls for a
treatment with a difference. To infer rashness or aegligence on the part
B of a professional, in particu Jar a doctor, additional considerations apply.
A case of occupational negligence is different from one of professional
negligence. A simple lack of care, an error of judgment or an accident,
is not proof of negligence on the part of a medical professional. So long
as a doctor follows a practice acceptable to the medical profession of
c . that day, he cannot be held liable for negligence merely because a better
alternative course or method of treatment was also available or simply
because a more skilled doctor would not have chosen to follow or resort
to that practice or procedure which the accused followed. When it
comes to the failure of taking precautions what has to be seen is whether
those precautions were taken which the ordinary experience of men has
D
found to be sufficient; a failure to use special or extraordinary precautions
which might have prevented the particular happening cannot be the
standard for judging th~ alleged negligence. So also, the standard of
care, while assessing the practice as adopted, is judged in the light of
knowledge available at the time .of the incident, and not at the date of
E trial. Similarly, when the charge of negligence arises out of failure to
use some particular equipment, the charge would fail if the equipment
was not generally available at that particular time (that is, the time of
the incident) at which it is suggested it should have been used.

(3) A professional may be held liable for negligence on one of the two
F
findings: either 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 he did possess. The
standard to be applied for judging, whether the person charged has been
negligept or not, would be Lhat of an ordinary competent person
G exercising ordinary skill in that profession. It is not possible for every
professional to possess the highest level of expertise or skills in that
branch which he practices. A highly skilled professional may be
possessed of better qualities, but that cannot be made the basis or the
yardstick for judging the performance of the professional proceeded
against on indictment of negligence.
H
JACOB MATHEWv. STATE [LAHOTI, CJ.] 339

(4) The test for determining medical negligence as laid down in Bo/am 's A
case (1957) I W.L.R. 582, 586 holds good in its applicability in India.

(5) The jurisprudential concept of '!egligence differs in civil and criminal
law. What may be negligence in civil law may not necessarily be
negligence in criminal law. For negligence to amount to an offence, the
element of mens rea must be shown to exist. For an act to amount to
B
criminal negligence, the degree of negligence should be much higher
i.e. gross or of a very high degree. Negligence which is neither gross
nor of a higher degree may provide a ground for action in civil law but
cannot form the basis for prosecution.
c
(6) The word 'gross' has not been used in Section 304A of !PC, yet it is
settled that in criminal law negligence or recklessness, to be so held,
must be of such a high degree as to be 'gross'. The expression 'rash
or negligent act' as occurring in Section 304A of the !PC has to be read
as qualified by the word 'grossly'.
D
(7) To prosecute a medical professional for negligence under criminal law
it must be shown that the accused did something or failed to do
something which in the given facts and circumstances no medical
professional in his ordinary senses and prudence would have done or
failed to do. The hazard taken by the accused doctor should be of such E
a nature that the injury which resulted was most likely imminent.

(8) Res ipsa /oquitur is only a rule of evidence and operates in the domain
of civil law specially in cases of torts and helps in determining the onus
of proof in actions relating to negligence. It cannot be pressed in service
for determining per se the liability for negligence within the domain of F
criminal law. Res ipsa loquitur has, if at all, a limited application in trial
on a charge of criminal negligence.

In view of the principles laid down hereinabove and the preceding
discussion, we agree with the principles of law laid down in Dr. Suresh
Gupta's case [2004] 6 SCC 422 and re-affirm the same. Ex abundanti
G
cautela, we clarify that what we are affirming are the legal principles laid
down and the law as stated in Dr. Suresh Gupta's case. We may not be
understood as having expressed any opinion on the question whether on the
facts of that case the accused could or could not have been held guilty of
criminal negligence as that question is not before us. We also approve of the H
340 SUPREME COURT REPORTS (2005] SUPP. 2 S.C.R.

A passage from Errors, Medicine and the Law by Alan Merry and Alexander
McCall Smith which has been cited with approval in Dr. Suresh Gupta's case
(noted vide para 27 of the report).

Guidelines re: prosecuting medical professionals

B As we have noti'ced hereinabove that the cases of doctors (surgeons and
physicians) being subjected to criminal prosecution are on an increase.
Sometimes such prosecutions are filed by private complainants and sometimes
by police on an FIR being lodged and cognizance taken. The investigating
officer and the private complainant cannot always be supposed to have
C knowledge of medical science so as to determine whether the act of the
accused medical professional amounts to rash or negligent act within the
domain of criminal law under Section 304-A of IPC. The criminal process
once initiated subjects the medical professional to serious embarrassment and
sometimes harassment. He has to seek bail to escape arrest, which may or
may not be granted to him. At the end he may be exonerated by acquittal
D or discharge but the loss which he has suffered in his reputation cannot be
compensated by any standards.

We may not be understood as holding that doctors can never be
prosecuted for an offence of which rashness or negligence is an essential
ingredient. All that we are doing is to emphasize the need for care and caution
E
in the interest of society; for, the service which the medical profession renders
to human beings is probably the noblest of all, and hence there is a need for
protecting doctors from frivolous or unjust prosecutions. Many a complainant
prefers recourse to criminal process as a tool for pressurizing the medical
professional for extracting uncalled for or unjust compensation. Such malicious
F proceedings have to be guarded against.

Statutory Rules or Executive Instructions incorporating certain guidelines
need to be framed and issued by the Government of India and/or the State
Governments in consultation with the Medical Council of India. So long as
it is not done, we propose to lay down certain guidelines for the future which
G should govern the prosecution of doctors for offences of which criminal
rashness or criminal negligence is an ingredient. A private complaint may
not be entertained unless the complainant has produced prima facie evidence
before the Court in the form of a credible opinion given by another competent
doctor to support the charge of rashness or negligence on the part of the
H accused doctor. The investigating officer should, before proceeding against
JACOB MA THEW v. STATE [LAHOTI, CJ.) 341

the doctor accused of rash or negligent act or omission, obtain an independent A
and competent medical opinion preferably from a doctor in government
service qualified in that branch of medical practice who can normally be
expected to give an impartial and unbiased opinion applying Bo/am 's test to
the facts collected in the investigation. A doctor accused of rashness or
negligence, may not be arrested in a routine manner (simply because a charge B
has been levelled against him). Unless his arrest is necessary for furthering
the investigation or for collecting evidence or unless the investigation officer
feels satisfied that the doctor proceeded against would not make himself
available to face the prosecution unless arrested, the arrest may be withheld.

Case at hand c
Reverting back to the facts of the case before us, we are satisfied that
all the averments made in the complaint, even if held to be proved, do not
make out a case of criminal rashness or negligence on the part of the accused
appellant. It is not the case of the complainant that the accused-appellant was
not a doctor qualified to treat the patient whom he agreed to treai. It is a case
D
of.non-availability of oxygen cylinder either because of the hospital having
failed to keep available a gas cylihder or because of the gas cylinder being
found empty. Then, probably.the ho"l'ltal may be liable in civil law (or may
not be - we express no opinion thereon) ~t the accused appellant cannot
be proceeded against under Section 304A !PC on the parameters of Bo/am 's E
test.

Result

The appeals are allowed. The prosecution of the accused appellant under
Section 304A/34 !PC is quashed. F

Alt the interlocutory applications be treated as dispose4 of.

K.G. Appeal allowed.

G