IN THE HIGH COURT OF DELHI AT NEW DELHI % Judgment reserved on :12.12.2025 Judgment pronounced on :19.01.2026 + CRL.M.C. 2358/2010 & CRL.M.A. 10046/2011 SANJEEVAN MEDICAL RESEARCH CENTRE .....Petitioner versus STATE & ANR .....Respondents Advocates who appeared in this case: For the Applicant : Mr. Gaurave Bhargava, Adv. For the Respondent : Mr. Hitesh Vali, APP for the State Mr. S.D. Singh, Mr. K. Prasad, Ms. Shweta Sinha & Mr. Siddharth Singh, Advs. CORAM HON’BLE MR JUSTICE AMIT MAHAJAN JUDGMENT 1. The present Application bearing CRL.M.A. No. 10046/2011 has been filed by the Applicants (who are Respondent Nos. 2/ Dr. D.K. Satsangi and Respondent No. 3/Mrs. Poonam Satsangi in Crl. M.C. 2358/2010 i.e. the original complainants) seeking recall/review of the impugned judgment dated 11.02.2011 passed by this Court in Crl. M.C. 2358/2010. 2. Vide the impugned Judgment dated 11.02.2011, this Court, in exercise of its inherent jurisdiction under Section 482 of the Code of Criminal Procedure, 1973 (‘Cr.P.C.’), had allowed the Crl. M.C. 2358/2010 filed by the Non-Applicants/Petitioners and quashed the criminal complaint instituted by the Applicants/Respondents, alleging that their son/Rahul Satsangi had died due to medical negligence while being treated at Petitioner No. 1/Sanjeevan Medical Research Centre, Darya Ganj. 3. Succinctly stated, a complaint was preferred by the Applicants/Complainants under section 156(3) of the CrPC. After taking cognizance, considering that the allegations pertained to death of their Son/Rahul Satsangi allegedly caused by medical negligence of the accused doctors working with Petitioner No. 1 and due to administration of antibiotics namely – azithromycin and levofloxacin which caused a drug-allergic reaction leading to his death, the learned MM directed the Director of All India Institute of Medical Sciences (‘AIIMS’), to constitute a Medical Board comprising of doctors specialized in the field to examine the matter and render its opinion on whether the death of the Applicants’ son was attributable to negligence on the part of the treating doctors. 4. However, before any opinion could be rendered by the Medical Board constituted by AIIMS pursuant to the aforesaid direction, the accused/Non-Applicants approached this Court under Section 482 of the CrPC, assailing the order of cognizance dated 04.06.2010 by way of the above Crl. M.C. No. 2358/2010. 5. It also transpires that parallelly, the Applicants/Respondents had approached the learned National Consumer Disputes Redressal Commission (‘NCDRC’) with similar allegations seeking compensation, whereby, vide order dated 30.09.2010, the learned NCDRC had also directed the Director, AIIMS, to constitute a multi-disciplinary Board of Doctors to furnish a prima facie opinion regarding the alleged medical negligence. 6. Undisputedly, the Medical Board of AIIMS, comprising of 7 expert members, upon examination, submitted its report dated 26.10.2010, opining that there was no material to suggest any gross negligence on the part of the treating doctors or the hospital. The relevant extract is reproduced as under: - “xxx xxx xxx Following the deposition of Dr. Prem Aggrawal, the board members carried forward the deliberations on this matter and from the available facts, medical records, etc. concluded as follows: * Late Mr. Rahul Satsangi was suffering from Duchenne muscular Dystrophy * No documented medical evidence in the form of previous medical reports especially echocardiography report, past medical records, etc is available to the board members to know about the pre morbid cardio-respiratory status of late Mr. Rahul Satsangi as according to the complainant Dr. D K Satsangi, they have been lost during the course of shifting of their house. * The X-Ray chest of late Mr. Rahul Satsangi is indicative of a patch of opacity and after clinical correlation with case presentation, the presenting condition of Late Mr. Rahul Satsangi warranted treatment on the lines of pneumonitis. * Cardiac involvement is known to occur in patient with Duchenne's muscular dystrophy. The literature does not suggest that Levofloxacin and Azithromycin are contraindicated in such cases. These drugs can be administered to such patients under controlled conditions following due precautions. * Though medical records and nursing notes do not clearly indicate that Azithromycin was given as an infusion however, the time mentioned for Azithromycin and next drug administration suggest that it could have been given over a period of 30 minutes. * The records also suggest that patient had an acute worsening with shivering and cardio respiratory arrest after the test dose of Levofloxacin. * The sequence of events suggest the patient had cardio respiratory arrest which could have been due to an arrhythmia or drug reaction following which the patient was shifted to ICU where cardio respiratory resuscitation was carried out. However, the patient could not be revived and died in the ICU. * The board gave its final opinion as under: THERE IS NO EVIDENCE TO SUGGEST THAT THERE WAS ANY GROSS NEGLIGENCE ON THE PART OF THE TREATING DOCTORS/HOSPITAL IN THE TREATMENT OF UTE Mr. RAHUL SATSANGI IN THE SAID MATTER.” (emphasis supplied) 7. The record further reveals that prior to filing the criminal complaint, the Applicants had also approached the police in December 2009, seeking registration of an FIR. The concerned SHO, without registering an FIR, sought the opinion of the Director of Health Services, Government of NCT of Delhi, (‘DHS’) who, vide opinion dated 17.02.2010, opined that prima facie no gross negligence, rashness, or omission was involved in the treatment of the patient. The relevant extract is reproduced as under: - “ Sub: Enquiry in the case referred by office of the Dy. Commissioner of Police, Central District vide File No. 600/ SO-A-DCP/CENTRAL DISTT., DELHI, dated 21-01-2010 regarding medical opinion w.r.t. rashness / negligence / opinion. A committee was constituted to scrutinize the records regarding the complaint from the office of DCP, Central District against Dr. Anupam, Dr. Prem Aggarwal & Dr. Nusrat regarding medical opinion with regard to rashness/negligence/omission if any in the treatment of Mr. Rahul Satsangi admitted at Sanjeevan Hospital on 24-10-2009 with Dr. S. Bhattarcharjee, Director Health Services – Chairman Dr. L.C. Thakur, Director Prof. HOD Neurology, GTB Hospital and UCMS - Expert Member Dr. S.V. Madhu, Prof. Medicine, GTB Hospital and UCMS - Expert Member The Committee met at 2: 00 o'clock on 17-02-2010 in the office of DHS. The committee scrutinized all the relevant documents and the file including the complaint, statement of the doctors concerned as well as the hospital records. After scrutiny of all the relevant files/documents, it appears that • As per hospital records, Mr Rahul Satsangi, age 20 years, was patient of Duchenne Muscular Dystrophy who presented to Dr. Anupam, a qualified physician at Sanjeevan Hospital on 24-10-2009 with complaints of fever and cough for 4 days duration. • As per the records of the hospital, the physician clinically examined the patient an ordered an X- ray chest which showed left lower zone opacity query consolidation. • As per hospital records. Dr. Anupam after evaluation of the patient on 24-10-2009 suspected lower respiratory tract infection (pneumonia) and accordingly prescribed antibiotics l.V. Azithromycin and l.V. Levefloxacin after the test dose. • As per the records of hospital, soon after the administration of l.V. Levefloxacin, the patient had chills and rigors with a fall of Blood Pressure and was shifted to the ICU for further management. • As per the records of hospital, all the resuscitative measures were carried out in the ICU including temporary pacing and consultation with the Sr. Cardiologist. The patient however, could not be saved. The Board is of the opinion that the treatment and the management given to the patient was appropriate and prima facie there is no gross rashness/negligence/omission involved in the treatment/management of the patient.” (emphasis supplied) 8. Thereafter, the matter was referred by the Deputy Commissioner of Police to the learned Delhi Medical Council (‘DMC’) for its opinion. The Disciplinary Committee of the learned DMC, consisting of six doctors, vide Order dated 01.10.2010 and 03.11.2010 observed that Dr. Anupam Jena (the main accused) had “failed to exercise reasonable degree of knowledge” expected of an ordinary prudent doctor and, accordingly, directed removal of his name from the State Medical Register for a period of one month. The relevant extracts of the report of the learned DMC are as under: - “ XXX XXX XXX In light of the above, the Disciplinary Committee make the following observations: - 1) It is noted on examination of original x-ray No. 304 dated 24.10.2009 of late Rahul that radiologically there was no significant evidence of pneumonia. In fact, it was suggestive of cardiomegaly as was reported by Dr. Nidhi Bhatnagar. However, based on the overall clinical assessment, in patient with presence of a co-morbid condition i.e. Duchenne Muscular Dystrophy, Dr. Anupam Jena was justified in making the provisional diagnosis of pneumonia and admitting the patient in the Hospital despite the absence of radiological sign which may not be evident in the early stage of pneumonia. To prescribe I.V. Azithromycin and Levofloxacin as drugs for treatment after test dose, can also not be faulted as the same are the recommended drugs for pneumonia. However, the administration of test dose of aforementioned drugs intravenously is not recommended and should not have been prescribed in the patient with a history of drug allergy. 2) It is noted from the nurses record (management chart) of the said Hospital that the patient was administered on 24.10.2009, Inj. Azithromycin 500 mg I.V. at 2.30 pm and test dose of Inj. Levofloxacin 0.1 ml I.V. was given at 3 pm, subsequent to which the patient had a severe drug reaction as is evident from his having chills, rigors and restlessness. The complication of drug reaction was countered by administration of Inj. Efcorin, Inj. Avil, IV DNS as per standard protocol. Unfortunately the patient's condition worsened and in spite of all resuscitative measures he could not be revived and was declared dead at 5.30 pm (24.10.2009). It is observed that the severe drug reaction exacerbated the co-morbid condition of the patient resulting in his death. In light of the observations made hereinabove, it is the decision of the Disciplinary Committee that Dr. Anupam Jena failed to exercise reasonable degree of knowledge which was expected of an ordinary prudent doctor, by prescribing administration of test dose of antibiotics viz. Azithromycin and levofloxacin intravenously contrary to standard protocols and especially in a patient with a known history of drug allergy. The Disciplinary Committee, therefore, recommends that the name of Dr. Anupam Jena (DMC registration No. 46628) be removed from State Medical Register of Delhi Medical Council for a period of one month. The Decision of Delhi Medical Council holding the above named doctor guilty of medical negligence is final. However, the Order directing the removal of name from the State Medical Register of Delhi Medical Council shall come into effect after 30 days from date of this Order.” (emphasis supplied) 9. The challenge to the above report by DMC by Dr. Anupam Jena, before the Ethics Committee of the Medical Council of India (‘MCl’), was dismissed on 18.05.2011, with the following observations: - “Subject: Appeal against order dated 03.11.2010 passed by Delhi Medical Council made by Dr. Anupam Jena. Sir, 1 am directed to inform you that the above mentioned matter was considered by the Ethic: Committee of the Council constituted by the Hon'ble Board of Governors, at its meeting held on 10" May, 2011 and it was decided as under:- "The Ethics Committee considered the appeal filed by Dr. Anupam Jena against the Order passed by Delhi Medical Council dated 03.11.2010. By the said Order. Delhi Medical Council has held Dr. Anupam Jena guilty of professional misconduct and has imposed punishment of removal of name of Dr. Anupam Jena from the State Medical Register of Delhi Medical Council for a period of one month. We have perused the grounds of appeal on which the order passed by Delhi Medical Council and have gone through the relevant treatment records as well the oral deposition made by both the parties on 5/4/2011. From the record it appears that Dr Jena diagnosed the patient as a case of pneumonia and prescribed the medicines ie. IV Azithromycin and IV Levofloxacin, Patient's father had informed Dr Jena bout patients history of various allergies and the fact that he has multisystem complications due to his original condition a Duchene Muscular Dystrophy. On perusal of the papers the Ethics Committee found that Dr. Anupam Jene had not exercised due care and precaution while treating the patient especially with a known history of drug allergy and co-morbid condition. Dr Jena ought to have made sure that in view of patients co morbidities adequately trained personnel is available at the time of giving test dose though he had prescribed the: medicines correctly and in good faith. The committee is of the opinion that allegation of patients father, Dr Satsangi, that IV Azethromycin was give as a bolus against the standard practice of giving it as an infusion can not be substantiated from the available records. The Ethics Committee does not find any infirmity in the order passed by Delhi Medical Council, therefore, the Ethics Committee recommends the dismissal of the appeal filed by Dr. Anupam Jena against the order of Delhi Medical Council dated 03.11.2010." (emphasis supplied) 10. The above captioned Petition seeking quashing was heard at length. This Court, vide the impugned judgment dated 11.02.2012, took into consideration the opinion of the DHS dated 17.0.2010, the report of AIIMS dated 26.10.2010, as well as the decision dated 03.11.2010 of the DMC (which affirmed the decision of the earlier opinion dated 01.10.2010) and it was categorically observed that two boards, one of DHS and one of AIIMS had given a clean chit to the accused/Petitioners/Non-Applicants by observing that there is no gross negligence/recklessness attributable to the treating doctors. Hence, the Petition was allowed, the order of cognizance was set-aside and the criminal proceedings were quashed. 11. Aggrieved by the impugned judgment dated 11.02.2011, the Applicants/Respondents filed a Special Leave Petition bearing SLP (Crl.) No. 4642/2011 before the Hon’ble Supreme Court. On 11.07.2011, the same was withdrawn with liberty to approach this Court. 12. Subsequent to withdrawal of the SLP, the Applicants filed the present application bearing CRL.M.A. No. 10046/2011 under Section 482 Cr.P.C. seeking recall of the impugned judgment dated 11.02.2011. 13. At the initial stage, notice in the present application was issued by this Court limited to the question of maintainability. The question of maintainability was decided vide Order dated 03.02.2012 and it was observed that the present Application should be disposed on merits. 14. I have perused the documents filed and material placed on record. 15. Before addressing the grounds raised in the recall application, it is necessary to reiterate the foundational reasoning which led this Court to allow the petition under Section 482 Cr.PC in the first instance. 16. The jurisdiction under Section 482 Cr.PC is meant to prevent abuse of the process of court and to secure the ends of justice. In cases involving allegations of medical negligence, the Supreme Court has consistently cautioned that criminal law must not be set in motion lightly to prevent undue harassment of medical professionals. 17. It is no more res-integra that a complaint alleging criminal medical negligence by doctors should not ordinarily set the criminal law in motion, unless an independent opinion is sought. The Hon’ble Apex Court in Jacob Mathew v. State of Punjab, (2005) 6 SCC 1, while laying down guidelines for prosecution of doctors in the cases of criminal medical negligence, had observed as under: - “52. 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 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 accused doctor. The investigating officer should, before proceeding against the doctor accused of rash or negligent act or omission, obtain an independent 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 the Bolam [(1957) 1 WLR 582 : (1957) 2 All ER 118 (QBD)] 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 has been levelled against him). Unless his arrest is necessary for furthering the investigation or for collecting evidence or unless the investigating officer feels satisfied that the doctor proceeded against would not make himself available to face the prosecution unless arrested, the arrest may be withheld. ” (emphasis supplied) 18. Further, in the case of Suresh Gupta vs. Govt. of N.C.T. of Delhi and Ors., (2004) 6 SCC 422, Dr. Suresh Gupta, who was a Plastic Surgeon by profession, made a wrong incision while performing a minor procedure on the nasal cavity of the patient, due to which the blood entered his respiratory canal and thereby, causing the death of the patient. Consequently, criminal proceedings under Section 304A of the IPC, for causing death by negligence, were launched against Dr. Gupta. However, the Apex Court, while relying on the post-mortem report and the opinion of the three medical experts of the Special Medical Board, observed that the negligence in 'not putting a cuffed endotracheal tube of proper size in the nasal cavity, in a manner so as to prevent asphyxiation, was not sufficient to impose criminal liability on the doctor. It was observed that: - “20. For fixing criminal liability on a doctor or surgeon the standard of negligence required to be proved should be so high as can be described as "gross negligence" or recklessness". It is not merely lack of necessary care, attention and skill. The decision of the House of Lords in R. v. Adomako (Supra) relied upon on behalf of the doctor elucidates the said legal position and contains following observations: - "Thus a doctor cannot be held criminally responsible for patient's death unless his negligence or incompetence showed such disregard for life and safety of his patient as to amount to a crime against the State." 21. Thus, when a patient agrees to go for medical treatment or surgical operation, every careless act of the medical man cannot be termed as 'criminal'. It can be termed 'criminal' only when the medical men exhibits a gross lack of competence or inaction and wanton indifference to his patient's safety and which is found to have arisen from gross ignorance or gross negligence. Where a patient's death results merely from error of judgment or an accident, no criminal liability should be attached to it. Mere inadvertence or some degree of want of adequate care and caution might create civil liability but would not suffice to hold him criminally liable. 22. This approach of the courts in the matter of fixing criminal liability on the doctors, in the course of medical treatment given by them to their patients, is necessary so that the hazards of medical men in medical profession being exposed to civil liability, may not unreasonably extend to criminal liability and expose them to risk of landing themselves in prison for alleged criminal negligence.” (emphasis supplied) 19. Applying these settled principles that criminal liability of a doctor arises only in cases of “gross negligence or recklessness”, and not in cases of mere error of judgment or professional lapse, this Court found that since two independent expert bodies, namely the DHS and the AIIMS Medical Board, had opined that there was no gross negligence attributable to the treating doctors, the criminal complaint, if permitted to proceed, would amount to subjecting the accused/Petitioners to a full-fledged criminal trial despite absence of prima facie material meeting the threshold of “criminal negligence” as per the settled law. 20. It was in this background that this Court exercised its inherent powers to prevent abuse of the criminal process and quashed the complaint. 21. At this juncture, before adverting to the merits of the recall Application, it would be apposite to mention that a review is not an appeal in disguise. The power of recall or review can be exercised only where there exists an error apparent on the face of the record, and not where the Applicants/Respondents seeks a reappreciation of evidence or a rehearing on merits. 22. The principal grievance of the Applicants is that this Court wrongly discarded the findings of the Disciplinary Committee of the learned DMC, which had found Dr. Anupam Jena guilty of “medical negligence and misconduct”. 23. This submission proceeds on an erroneous assumption. The impugned judgment dated 11.02.2011 does not discard the DMC report and has addressed the same as under: - “6. I have gone through the order of Medical Council and the same is silent about the opinions given by other two Boards and has not discussed these opinions at all. The order also does not show as to who, on behalf of Delhi Medical Council considered the issue of Medical negligence of Dr. Anupam. In any case, Delhi Medical Council has given its own reasons which are contradictory to the reasons given by the other two Boards.” (emphasis supplied) 24. The emphasis placed by the Applicants on the decision of the learned DMC dated 03.11.2010 to contend that “medical negligence” having been recorded against Dr. Jena, which has been over-looked and the criminal proceedings deserve to be revived, is wholly misconceived. 25. A plain and contextual reading of the said decision of the learned DMC reproduced in the preceding paragraphs makes it manifest that the finding of “medical negligence” is confined to a limited professional lapse in the mode of administration of a test dose of antibiotics, and not a finding of gross negligence, recklessness or rash conduct so as to attract criminal culpability. Significantly, the Disciplinary Committee expressly held that the provisional diagnosis of pneumonia, the decision to admit the patient, as well as the choice of antibiotics, were all justified and in conformity with accepted medical practice. The “medical negligence” recorded at the end pertains only to deviation from standard protocol in administering a test dose intravenously in a patient with a known history of drug allergy, for which a minor disciplinary penalty of temporary removal from the medical register for one month was imposed. Such a finding, rooted in regulatory and professional standards, cannot be elevated to the level of criminal negligence required under Section 304-A of the IPC, when it is trite that every lapse or error of judgment by a medical professional does not give rise to criminal prosecution, unless the conduct complained of is so gross or culpable as to show a disregard for life and safety. 26. It also cannot be lost sight of that the proceedings before the learned DMC are disciplinary proceedings governed by the Delhi Medical Council Act, 1977. The standard applied therein is materially different from the standard required to prosecute a person for a criminal offence under Section 304-A of the IPC. Finding of professional misconduct or negligence in disciplinary proceedings cannot automatically translate into criminal culpability and even otherwise, the findings of the Disciplinary Committee of the learned DMC, did not disclose the element of “gross negligence or recklessness” by the accused Doctors, required to sustain criminal prosecution for medical negligence. Thus, the decision of the learned DMC, even if taken at its highest, does not dilute the basis of the impugned judgment. 27. Further, this Court also finds no merit in the argument of the Applicants that after passing of the impugned judgment the Applicants had sought some information from the learned DMC, which in turn had informed them that Dr. S. Bhattaeharjee, who had earlier as the chairman of DHS and had opined that there is no “gross negligence” in the treatment of Rahul Satsangi, himself was a member of the learned DMC and had subsequently confirmed the decision of the disciplinary committee of the learned DMC. At the cost of reiteration, the opinions of the AIIMS and DHS boards bear no relation to “misconduct” or disciplinary proceedings. Even assuming a common expert member across panels, the initial view (absence of “gross negligence” with respect to Section 304A of the IPC) and later assessment (specifically with respect to “misconduct and medical negligence” for disciplinary purposes) are neither contradictory, nor does the latter withdraw the former. 28. The contention that the DMC being a statutory body, its opinion ought to have been treated as conclusive, is also legally untenable. The observations of the Medical Council cannot be binding upon the criminal courts as the function of the criminal court is to independently assess whether the ingredients of a criminal offence are prima facie made out. 29. The Applicants further have alleged that this Court misread the AIIMS report and wrongly relied upon the DHS report. A careful reading of the judgment dated 11.02.2011 shows that the conclusions of the AIIMS Medical Board have been faithfully recorded. The Board unequivocally stated that there was no evidence of gross negligence on the part of the treating doctors. The DHS Report similarly did not attribute “gross negligence” to the accused doctors or the nursing home. 30. Hence, this Court rightly declined to elevate one disciplinary opinion passed by the learned DMC with respect to the disciplinary misconduct and negligence, above the two expert medical opinions rendered in the specific context of criminal proceedings and the issue of “gross negligence” by the two independent boards constituted by AIIMS and DHS. 31. Further, the allegations of manipulation or bias are completely bald and unsupported. In any case, any allegations regarding the procedural lapses in the AIIMS and DHS Boards cannot be examined in recall proceedings as this Court cannot convert review jurisdiction into a fact-finding inquiry into the functioning of expert medical bodies. 32. It would also be pertinent to mention that during the pendency of the present proceedings before this Hon'ble Court the complaint (Consumer Complaint no. 22/2010) filed by the Applicants before the NCDRC for award of compensation for alleged negligence too came to be dismissed on merits vide judgment dated 01.04.2016 and no negligence, much less gross negligence, was found attributable to the accused doctors herein by the NCDRC. 33. Hence, there is nothing placed on record to reflect any infirmity in the impugned judgment and no document has been brought forth to show that any opinion with respect to “gross negligence” by the accused doctors to attract Section 304A of the IPC, was not considered while passing the impugned judgment. 34. No error apparent on the face of the record has been demonstrated and in the opinion of this Court, the judgment dated 11.02.2011 reflects a reasoned, balanced, and legally sound exercise of jurisdiction. 35. It emerges that the present application is, in substance, an attempt to reargue the matter on merits, to reopen concluded issues, and to substitute this Court’s judicial assessment with the Applicants’ subjective perception. 36. This Court is not unmindful of the profound anguish and irreparable loss suffered by the Applicants on account of the untimely demise of their young son. The pain of a bereaved parent is immeasurable and evokes the deepest sympathy. However, while the loss suffered by the Applicants/Respondents is tragic, the same by itself cannot furnish a legal foundation to revive criminal proceedings which, upon due consideration of the entire material, were found to be an abuse of the process of law. 37. In view of the above discussion, the present Application seeking recall/review of the judgment dated 11.02.2011 is dismissed on merits. 38. All pending applications stand disposed of. AMIT MAHAJAN, J JANUARY 19, 2026 CRL.M.C. 2358/2010 Page 1 of 1