A critically ill woman suffering from intestinal obstruction and suspected perforation was eventually advised urgent transfer to a higher medical centre with cardio-thoracic support.

The treating doctors were later cleared of negligence. The hospital, however, was not.

The distinction arose from what happened after the decision to transfer had already been made.

The patient was admitted in the early hours with severe abdominal pain, vomiting, breathing difficulty, circulatory shock, and worsening metabolic instability. Emergency treatment, investigations, intensive monitoring, vasopressor support, and specialist consultations were initiated soon after admission. CT imaging later revealed a highly complicated condition involving massive oesophageal dilation requiring specialised thoracic surgical backup beyond the hospital’s available infrastructure.

At that point, the doctors advised immediate transfer to a tertiary care centre.

The Commission found no fault with that clinical judgment.

Treatment records showed that the attending physicians had continuously attempted stabilisation according to accepted medical protocols and had appropriately recognised the limits of the hospital’s surgical capabilities. In medico-legal terms, the doctors crossed the Bolam threshold.

But the institutional response that followed came under intense scrutiny.

Although the transfer decision was reportedly taken around 12:30 PM after review of the CT scan, the patient remained at the hospital for several more hours before discharge formalities were completed. More critically, the hospital lacked a life-support ambulance capable of safely transporting such a critically unstable patient.

The family was left to arrange transfer independently.

The patient died while being shifted to another hospital.

The Commission treated this not as medical negligence by individual doctors, but as deficiency in institutional service. It observed that once a hospital decides a patient requires higher care unavailable at its own facility, its responsibility does not end with advice alone.

The duty of care extends through the transfer process itself.

That principle became decisive.

The Court noted that in emergency medicine, the “golden hour” may be lost not only through wrong treatment, but through administrative inertia, delayed discharge, absence of coordinated transfer systems, or failure to arrange critical transport infrastructure.

The hospital argued that specialised cardio-thoracic facilities were unavailable at its centre and that referral had therefore been medically appropriate. The Commission agreed with the referral decision, but held that the absence of a critical care ambulance and the delay in effectuating transfer amounted to a serious deficiency in service.

Compensation of ₹15 lakh was awarded against the hospital alone.

The ruling marks an increasingly important shift in medico-legal scrutiny: hospitals are judged not merely by what treatment they provide, but also by how safely and efficiently they transition critically ill patients when advanced care lies elsewhere.

IML Insight

Modern hospital liability extends beyond diagnosis and treatment into systems management, emergency coordination, and continuity of care.

Once a patient is identified as requiring higher-level intervention unavailable at a facility, timely transfer becomes part of treatment itself. Delays arising from discharge formalities, ambulance unavailability, or administrative indecision may attract liability even where treating doctors have otherwise followed accepted medical standards.

The case also reflects a broader legal trend: courts increasingly distinguish between individual clinical negligence and institutional deficiency in service. A doctor may satisfy the standard of care, while the healthcare system around that doctor may still fail the patient.

Source : Order pronounced by West Bengal State Consumer Disputes Redressal Commission on 6th May, 2026.