Few allegations in medical negligence are as serious as operating on the wrong organ. Such cases are exceptionally rare, yet when they occur, they shake the very foundation of patient safety because they represent a failure of the most basic safeguards that precede surgery.

A recent decision of the National Consumer Disputes Redressal Commission is a stark reminder of exactly that.

The patient had approached a surgeon with complaints of abdominal pain. Clinical examination, ultrasonography, intravenous urography and other investigations consistently pointed towards a severely hydronephrotic right kidney. The treatment plan was clear: the diseased right kidney required surgical removal. The patient was accordingly admitted, and a right nephrectomy was performed.

Even the immediate post-operative referral records documented that the right kidney had been removed.

But the patient's condition failed to improve.

Within weeks, fresh imaging at another hospital produced a shocking revelation. The diseased right kidney was still present inside the body, while the healthy left kidney was no longer visible. The patient was forced to undergo repeated dialysis and continued to struggle with renal failure before eventually succumbing to complications nearly two years later.

The defence adopted by the surgeon was unusual.

He did not seriously dispute that the left kidney had been removed. Instead, he argued that the surgery had commenced through a right-sided incision and that, anatomically, removing the left kidney through such an incision was virtually impossible. Since such an occurrence was medically unimaginable, he contended that he could not reasonably have anticipated it. Certificates and medical literature were relied upon in support of this explanation.

The Commission found the defence wholly unacceptable.

Every pre-operative investigation had clearly documented that the right kidney was diseased and that the left kidney was normal. More importantly, the surgeon himself admitted that although the operation had been planned on the right side, the left kidney had in fact been removed. What remained completely unexplained was how such a fundamental error could have occurred despite all pre-operative investigations consistently identifying the correct kidney.

The Commission also attached considerable weight to the findings of the expert Medical Board, the Uttar Pradesh Medical Council and the Medical Council of India, each of which independently concluded that the surgeon had been negligent. The Medical Council further recorded that the surgeon had failed to verify which kidney was being removed and had even relied upon a forged case sheet during the proceedings.

Describing the incident as one of the gravest instances of medical negligence to come before it, the Commission observed that this was one of those exceptional situations where the facts themselves overwhelmingly established negligence. It awarded compensation of ₹2 crore along with litigation costs to the patient's family.

The judgment underscores a principle that transcends surgical skill. Modern surgery depends not only on technical competence but also on disciplined adherence to basic safety protocols. Correct patient identification, correct-site verification, imaging correlation, operative planning and surgical time-outs exist precisely to prevent catastrophic errors of this nature.

When these elementary safeguards fail, even the most sophisticated operation cannot withstand medico-legal scrutiny.

IML Insight

Wrong-site and wrong-organ surgeries are recognised worldwide as "Never Events" because they are considered preventable through robust safety systems rather than advanced surgical expertise alone.

For surgeons and hospitals, this case reinforces that patient safety begins long before the first incision. Structured pre-operative verification, imaging review, surgical site confirmation, operative checklists and meticulous documentation are not merely administrative formalities; they are critical risk-management tools. When these safeguards are ignored or bypassed, courts are unlikely to view the resulting error as an exercise of clinical judgment, but as a preventable systems failure carrying the highest degree of medico-legal liability.

Source : Order pronounced by National Consumer Disputes Redressal Commission on 18th May, 2026.