State Consumer Disputes Redressal Commission
Shiv Saran Tripathi vs Sahara Hospital & Other on 24 February, 2023
Cause Title/Judgement-Entry STATE CONSUMER DISPUTES REDRESSAL COMMISSION, UP C-1 Vikrant Khand 1 (Near Shaheed Path), Gomti Nagar Lucknow-226010 Complaint Case No. CC/145/2015 ( Date of Filing : 20 Jul 2015 ) 1. Shiv Saran Tripathi Auraiya ...........Complainant(s) Versus 1. Sahara Hospital & Other Lucknow ............Opp.Party(s) BEFORE: HON'BLE MR. Rajendra Singh PRESIDING MEMBER HON'BLE MR. Vikas Saxena JUDICIAL MEMBER PRESENT: Dated : 24 Feb 2023 Final Order / Judgement Reserved State Consumer Disputes Redressal Commission U.P. Lucknow. Complaint Case No. 145 of 2015 1- Shri Shiv Sharan Tripathi s/o Shri Jai Prakash Narain Tripathi, R/o 83, Mohalla Banarsida, Near Nehru Inter Colege, Auraiya, U.P. ...Complainant. Versus 1- Sahara Hospital through Director, Viraj Khand, Gomti Nagar, Lucknow, Uttar Pradesh. 2- Director, Sahara Hospital, Viraj Khand, Gomti Nagar, Lucknow, Uttar Pradesh. 3- Dr. Anjali Somani, Sahara Hospital, Viraj Khand, Gomti Nagar, Lucknow, Uttar Pradesh. 4- The New India Assurance Co. Ltd., Office at, 3rd Floor, Arif Chamber-1, Kapoorthaha Complex, Aliganj, Lucknow-226020 ...Opposite parties. Present:- 1- Hon'ble Sri Rajendra Singh, Member. 2- Hon'ble Sri Vikas Saxena, Member Sri R.N. Pandey, Advocate for complainant. Sri Alok Kumar Srivastava, Advocate for OPs 1 to 3. None for the OP no.4. Date 10.3.2023 JUDGMENT
Sri Rajendra Singh, Member- In brief, the facts of the complaint case are that, that the complainant got her wife Smt. Sumena Tripathi admitted in Sahara Hospital, Gomti Nagar, Lucknow, on 18.09.2013 as she was pregnant and suffering from labour pain. A cesarean section was conducted by opposite party-3, Dr Anjali Somani on24.09.2013 and she gave birth to a male child and later on she was discharged from Sahara hospital on 10.10.2013. After five for six months, the wife of the complainant suffered from stomachache and as such the complainant took her for medical treatment at Sabhlok Surgical Clinic, 116-Akansha Udyan-II, Eldeco, Raebareily Road, Utrathia, Lucknow. The complainant spent a huge amount but she did not get any relief, then he contacted Dr. Gurdeep Singh on suggestion of some of the medical practitioners.
After a number of medical and pathological examinations, Dr. Gurdeep Singh started the medical treatment on 26.06.2014 , but the wife of the complainant got no relief. After seeing no improvement in the condition of his wife, the complainant contacted Dr Gyan Prakash Gupta , who is a famous doctor/surgeon and consulted him on 05.07.2014. Dr. Gyan Prakash also suggested a number of pathological examination and CT Scan and again the complainant had to bear huge expenses on the tests. After the examination conducted by Dr Gyan Prakash, it became clear that a sheer medical negligence was committed by Sahara Hospital during cesarean section of the complainant's wife and the post cesarean complications were its outcome as a foreign body was detected in the intestine of the SmtSumeena Tripathi.
The condition of the wife of the complainant turned very critical and she was deteriorating day by day, as such, she was referred to Dr. SD Maurya of Sachkhand Multispecialty Hospital, Bhawna Estate Road opposite Holi Public School, Sikandara, Agra. She was admitted there on 09.07.2014. Despite major complications and risk of her life occurred due to medical negligence of opposite parties, the surgery of the wife of the complainant was successfully conducted by Dr SD Maurya. The complainant took private loans from a number of relatives and other persons on a high rate of interest for the treatment of his wife. During the surgery of the complainant's wife, a sponge (bundle of cotton) was recovered from the intestine of SmtSumeena Tripathi which was negligently left in her intestine during her cesarean operation conducted by opposite party - 3. Dr SD Maurya also performed colostomy (colostomy is a surgical procedure that brings one and of the large intestine out through an opening, (stoma) was made in the abdominal wall, so that the stools/faecal matter moving through the intestine into a bag attached to the abdomen) for making an artificial orifice for the excretion of the faecal matter from the body of Smt. Sumeena Tripathi and attached a catheter.) The catheter remained for four months for artificial excretion and thereafter again a surgery was conducted by Dr SD Maurya to remove the catheter on 06.11.2014 , in which again huge expenses were incurred by the complainant. The wife of the complaint was under post-operative medical treatment under the medical supervision of Dr Col (Retd) S Sabhlokof Sabhlok Surgical Clinic. Due to ailment and bodily infection of the wife of the complainant, the infant (newly born male baby) was unable to get proper care, attention and nutrition and as such the infant got seriously ill and a lot of expenses were also incurred on his treatment. The wife of the complainant had been suffering from cardiac ailments and the entire history of her cardiac ailment was also disclosed by the complainant before the attending doctors of Sahara Hospital. The complainant's wife is still not well and is under medication. She is also unable to perform her routine work and is also unable to perform her domestic duties and take proper care of her children and other family members, due to which the complainant is unable to engage himself in his profession properly and had to suffer great loss in earnings. The complainant shall also not be able to pursue his profession in near future due to illness of his wife.
The medical negligence committed by the hospital highly endangered and risked the life of the complainant's wife and caused a great inconvenience, pain, trauma, suffering and adversity to the complainant and his family. Due to ailment and bodily infection of the wife of the complainant, the infant (newly born) namely Master Anjaney Tripathi was unable to get proper care, attention and nutrition and as such the infant got seriously ill and was admitted to the Regency Hospital Kanpur on 05.05.2014 and a lot of medical expenses amounting to Rs.50,944/- were incurred on his treatment. Due to medical treatment of his wife the complainant was unable to attend the institution, where he is serving and was also unable to provide private tuition and as such he again had to bear a heavy financial loss. The complainant and his family have suffered a huge financial mental and physical loss due to the medical negligence committed by the opposite parties. The opposite party - 1 is vicariously liable for the acts and omissions of its doctors, employees and staff and as such opposite party - 1 is also liable for all the consequences due to the above mentioned medical negligence.
The complainant has incurred huge medical expenses to the tune of Rs.536,261/- in the medical treatment of his wife. Besides the medical bills the complainant had to bear other expenses also like transportation, lodging, fooding etc. during the treatment of his wife, which is approximately to the tune of Rs.350,000/-. The complainant who is a private lecturer and employed at CHVSB Inter-College, Auraiya, on Rs.10,000/- per month from the aforesaid institution and also earns Rs.30,000/- per month by providing private tuitions i.e, a lump-sum amount of Rs.40,000/- per month. The complainant has unable to take private tuitions since the date of operation i.e. 24.09.2013, as such he suffered a big loss of earnings approximately to the tune of Rs.630,000/- the complainant also has about 15 bighas of fertile land and during the span of 21 months he was unable to see his farms and as such suffered a loss of approximately Rs.10 lakhs. The complainant also took private loan from the treatment of his wife at a very high interest rate. Due to financial loss and adverse situation the complainant's daughter had to discontinue her education for the last 21 months and in future also the complainant's children will have to suffer in their education due to financial crunch and their mother's illness. The complainant also incurred heavy expenses for engaging two maids for domestic help and nursing of his wife and also for nurturing his children. Due to a number of operations performed on the complainant's wife, due to opposite party's sheer negligence, the condition of the operation of heart has become critical and highly risky which might endanger the life of the complainant's wife in future. Though the lifelong mental agony and trauma suffered by the complainant, his wife and children, cannot be compensated in terms of money, but despite that the reasonable amount of Rs.30 lakhs is being claimed, from the opposite parties, against mental agony and trauma suffered by them and also for the future losses which may occur due to the medical negligence committed by the opposite parties. As such in view of the above mentioned facts the opposite parties are liable to pay a total medical claim of Rs.5,567,205/- to the complainant and his family.
A registered legal notice was sent by the complainant on 22 June 2015 to the opposite parties through his counsel but there had been no response from the opposite parties. On 01.12.2015 the wife of the complainant died due to the complications generated in consequence of the gross medical negligence committed by the opposite parties. Due to the trauma and agony, caused by the death of complainant's wife, the complainant became completely depressed and consequently suffered severe traumatic problem, hypertension and chest pain due to which the complainant is compelled to discontinue from his service. The loss of the life of complainant's wife, another amount of Rs.15 lakhs is being claimed for the discontinuance of service of the complainant and for nurturing of his children and amount of Rs.10 lakhs is being claimed from the opposite parties. So in total the complainant has claimed Rs.8,067,205/- from the opposite parties.
The opposite parties have submitted their written statement submitting that the instant complaint is being heard by the Hon'ble Forum without constituting the mandatory panel of doctors as held by the Supreme Court. It is essential to annex medical expert opinion before the notices issued to the alleged Dr/hospital in order to enable the courts/Consumer Forum to analyse whether privacy evidence of medical negligence is made up against the alleged doctors. The patient SmtSumeeta Tripathi was an unbooked pregnant lady G5P1+3 and was first seen in OPD (gynaecology) on 18.09.2013 as full-term pregnancy with serious heart disease. She was referred to and was seen by senior cardiologist Dr. R.K. Mishra and was admitted under his expert care in cardiac care unit on 21.09.2013. In view of her term pregnancy and serious decompensated heart disease cesarean section was considered safer for the women's health. The Cesarean Section (LSCS) was done on 24.09.2013 as a planned procedure after pre-anaesthesia and the surgical evaluation. The surgery was uneventful without any complications. Post-operatively she remained a febrile, ambulated early, resumed bowel and bladder functions satisfactorily and she made an uneventful speedy recovery. The complainant has stated that after five for six months and his wife suffered stomach ache and took treatment at Sabhlok Surgical Clinic, Lucknow but after spending huge amount on her treatment got no relief. To prove this fact there are no enclosureS of any investigations/bills of treatment/nature of treatment during this period. However a perception slip from Dr Sabhlok shows following notable points:
the patient had two previous abdominal surgeries - one mid line incisional hernia scar is clearly indicated in the diagram drawn by the surgeon on 25.03.2014 apart from the lower transverse cesarean scar.
The details of this clearly depicted second. Surgery (performed through the middle incision) is desirable.
This indicates that Smt. Sumeena Tripathi had undergone another abdominal surgery after being discharged from Sahara hospital on 01.10.2013.
The diagram drawn by senior surgeon Dr Sablok very clearly show two surgical scar on her abdomen, a low transverse cesarean scar and the vertical scar with an incisional hernia.
In the same prescription on25.03.2014, she is advised a plan of incisional hernia repair and the complainants of patient at that time noted as -incisional hernia, -upper respiratory infection, -dyspepsia.
She had been advised city CT Scan abdomen with contrast On 25.03.2014 reports of which are not enclosed. The material facts related to the case like the CT scan abdomen as advised by Dr Sabhlok on 25.03.2014 and the facts about a second abdominal surgery has been intentionally suppressed. The specs of air in the abdomen may be seen in any bowel fistula and maybe misinterpreted on the CT scan as gauze/cotton with air.
As per Dr Sabhlok's advice on 25.03.2014 she visited Sahara Hospital at 2 PM on 25.03.2014 . She consulted Dr RK Mishra (consultant cardiologist) and underwent tests like ECG and ECHO. Despite coming to Sahara Hospital on 25.03.2014 for some unrelated problem, the patient did not show up in gynaecology/surgery OPD for any stomach pain.
Another interesting observations is that the complainant has re enclosed the same prescription price after raising the date. This indicates clear foul play.
As alleged by the patient she thereafter consulted Dr Gurdeep Singh on 26.06.2014 . But there are no details of treatment taken, investigations, done and medical/surgical bills during the three months. From 25.03.2014 to 26.06.2014. The complainant has not attached to any such report showing the original plates of CT scan.
As per the hospital surgical protocol, the operation instruments, needles et cetera were counted and doubly checked by two surgical assistants, before closing the abdomen, this is meticulously documented in the operative notes. It is strongly objected that a sponge (bundle of cotton) was left negligently in the intestine during cesarean conducted at Sahara Hospital. The type of response used in Sahara Hospital OT is a travel stitched material marked with a radio opaque blueline and can be clearly distinguished on x-ray as well as CT scan abdomen. The Sahara Hospital do not use bundle of cotton during surgery. It is wrong to say that any negligent practice being followed at Sahara Hospital. The complainant has made false statement and labelled false allegations against the hospital only with intent to malign the goodwill of the opposite party. The patient had undergone surgery - exploratory laparotomy - foreign body,? Surgical sponge excision -Sigmoid colon primary repair - covering Ialeostomy done, performed by Dr. S.D. Maurya on 11.07.14 and 06.11.14 at Sachkhand Multispecialty Hospital, Agra . The complainant has nowhere test any such images/videos of the surgical procedure performed on the said date. The histopathology reports dated 14.07.2015 shows no mention of foreign body in the specimen received. The histopathology reports only state that there was a perforated bowel segment; however it does not mention the presence of any foreign body in the surgically removed specimen. The surgeon has also not confirmed recovery of foreign body during surgery and is also not sure about it in his discharge summary which is further not substantiated by the histopathology report submitted. If the sponge was recovered during surgery it should also contain the blueline which is used at Sahara Hospital, however this is not mentioned in the discharge summary provided.
It is submitted that Smt. Sumeena Tripathi had a serious critical cardiac ailment and had a very high risk of morbidity and mortality associated for any surgical procedure. Such patients sometimes die during surgery in the operating table which had been duly explained to the patient and attendants before performing surgery on her at Sahara Hospital and consent was documented in the file before surgery. The obstetric surgeon undertook all the risks to perform surgery in good faith and Sahara Hospital contributed and extended all facilities to the best of their capacity to save the life of patient. It may be noted here that the surgeon is an employee of Sahara hospital and gained no extra advantages monetary or otherwise from this surgery, this was performed only for the benefits of the seriously ill patient in good faith. The complainant's wife already had a long-standing heart disease because of which she had breathlessness even on walking. These patients are unable to carry out household work, irrespective of childbearing surgery or infection et cetera. There is no deficiency in service or negligence on the part of the opposite parties. The patient was given better treatment, care and cure.
The complainant did not suffer by any act of opposite parties. It is submitted that the treatment given by the opposite parties at the time of admission was medically appropriate and prompt in accordance with the medical report of the patient. Before starting the treatment the patient and her husband has gone through the benefits and consequences of the treatment which was very well explained to them by the opposite parties. It is wrong to say that there is any negligence in providing medical treatment to the patient. The patient did not come for follow-up in the Gynaecology Outpatient Department even once, after being discharged on 01.10.2013, as advised at the time of discharge from Sahara Hospital.
The treatment given by the opposite parties was medically appropriate and after the consent of the complainant and her husband. If the complainant was unable to do his business then the same was due to other reasons and not due to treatment given by the opposite parties. The opposite parties never caused mental or physical agony or financial loss to the complainant. Apart from the above, the opposite party has purchased an insurance policy by which the insurance company has agreed to indemnify the opposite parties against all the claims which may arise from the fault and services given by the opposite party no 1,2 and 3 as such for any liability which may arise from the service, of the hospital, the liability if any of the same shall be discharged by the insurance company. No cause of action for filing the present complaint has ever arisen. It is complainant who has created a false story without any evidence and basis and has filed the present complaint to extort money from the opposite parties. The complainant is not entitled for any relief from this Hon'ble court against the opposite parties.
We have heard the learned counsel for the complainant Mr. R.N. Pandey and counsel for the opposite parties no.1 to 3 Mr. Alok Kumar Srivastava. None appeared on behalf of the insurance company. We have perused the pleadings, evidence is and documents placed on record.
In this case cesarean childbirth took place on 24.09.2013 in Sahara Hospital by Dr. Anjali Somani . At that time there is no note regarding any sponge or cotton in the abdomen. First we should know that what is sponge or cotton left in the body of a person during operation. It is called "Gossypiboma".
Now first of all we have to see that what is "Gossypiboma".
A mass formed around a cotton matrix left within the body is termed gossypiboma or textiloma. It is a rare complication of surgery most commonly seen after abdominal surgery. The time of presentation may range from early post-operative period to several decades later. We herein report on a case of gossypiboma. A 42-year old woman admitted to our hospital with abdominal mass. She had undergone a caesarean operation 2 years previously. The mass in the right quadrant was suspected by abdominal ultrasound and magnetic resonance imaging. The mass was removed by laparoscopy excision and the final diagnosis was gossypiboma.(V Bilali, S Bilali, A Mitrushi, R Pirushi, H Nina, E Ktona) Gossypiboma is a sponge or a swab retained involuntarily within the body during a surgical procedure. The incidence of retained surgical items is difficult to estimate due to under-reporting of cases due to medico legal implications. The reported incidence varies from 1 per 3000 to 5000 procedures.1 The wide variation in the incidence depends on the type of procedure, operation theatre personnel, experience of the surgeon, frequency of reporting of adverse incidents and hospital policies. The diagnosis is challenging because of variation in clinical and imaging presentation depending on time elapsed after surgery. Ultrasonography (USG), computerized tomography (CT) and magnetic resonance imaging are usually used as important diagnostic tools. The incidence of this catastrophic complication can be significantly reduced by strictly adhering to World health organization (WHO) surgical safety checklist. 2 Awareness among surgeons and radiologists can lead to early diagnosis and intervention, preventing further complications.
CASE REPORT A 23 years old P1L1 female with history of gestational hypertension presented on day 18 post Lower segment cesarean section (LSCS) with complaints of fever and generalized pain abdomen for 10 days. She had delivered a healthy 2.7 kg, male baby, at 36 weeks period of gestation via emergency LSCS in view of premature rupture of membranes (PROM) with gestational hypertension, 18 days back. One blood transfusion was done post LSCS. Patient was kept at that hospital for 8 days post LSCS and was discharged thereafter with no complaints. The day after discharge, she developed fever with chills and rigor followed by pain abdomen and abdominal distension for which outpatient management was done. Thereafter, patient went to another hospital for same, she was admitted and was managed conservatively. As the symptoms were not subsiding, she was referred to our hospital for further management. On examination- patient had high grade fever, with moderate degree of anemia with pedal edema. Abdomen was distended, generalized tenderness was present and the uterus could not be palpated. On pelvic examination, the cervical os was closed, size of the uterus could not be appreciated due to tenderness and lochia was healthy. On investigation hemoglobin was 8.9 gm% with normal leucocyte count and platelet count- 6,65,000. Ultrasonography showed peritonitis with large multiple loculated collections in the perihepatic, perisplenic space, paracolic gutter and the pelvis; with the largest collection measuring approximately 500 cc on the left side for which a pigtail catheter was inserted and the pus was drained, by the sonologist.
DISCUSSION A retained surgical sponge or gossypiboma is an underreported complication occurring most commonly after abdominal surgeries. The clinical appearance of gossypiboma can vary from being asymptomatic to vagueand varied symptoms like fever, abdominal pain, distension, nausea, vomiting, discharge from stitch site, weight loss, palpable mass. Retained surgical items can cause two different types of tissue reaction; first is exudative reaction which presents early in the postoperative period, and the second is aseptic fibrous reaction, which is slow and can remain asymptomatic for years.3 Stawicki et al showed that the most common clinical and diagnostic findings were focal pain, fluid or abscess collection or mass, and the most common pathological findings were exudative reaction, fibrosis, purulence, or abscess.4 CT scan is the first-choice diagnostic imaging technique for excluding gossypibomas because of its higher sensitivity, which shows typical spongiform pattern or heterogeneous central areas due to gas, calcification, and radiopaque markers.5,6 Ultrasound can also be used as a diagnostic tool which shows a poorly defined echogenic area with intense posterior acoustic shadowing.7 Prevention is always better than cure and that too in a scenario where surgical removal is the cure. WHO surgical safety checklist should be used to reduce reliance on memory. Counting mops and instruments before operation, just before closing abdomen and after the operation should be made a routine. The avoidance of conditions leading to human error like, fear, anxiety, anger, time pressure, interruptions; avoidance of nursing staff change in between the operation decrease such mishaps. In case of necessity of nursing staff change in between the surgery due to unavoidable circumstances, proper handover about the counts should be given. Computer-assisted system can be used for counting sponges using barcodes, which can detect significantly more counting discrepancies compared to traditional counting protocols and can further decrease the incidence of such events.
CONCLUSION WHO surgical safety checklist should be strictly adhered to. In case of discrepancy in count, appropriate action should be taken immediately to decrease morbidity of the patient. In case, patient presents with post-operative complications like fever with abdominal pain or discharge from wound, a high index of suspicion for retained sponge should be considered.
A Case Study :
A 27-year-old lady presented with discomfort in periumbilical area since one month ago. The only positive point in her previous history was a cesarean section five years back. Vital signs were normal. On abdominal examination, a round mobile mass was palpable. All routine lab data were normal. Abdominal X-ray was in favor of retained sponge (figure 1). CT scan confirmed the diagnosis (figure 2). Exploratory laparotomy revealed an encapsulated sponge surrounded by omentum, which was removed (figure 3, 4). Postoperative course was uneventful.
Abdominal CT scan showing a round well-defined soft-tissue mass containing an internal high-density area in the mid-abdomen.
Mini-laparotomy revealed gossypiboma (grasped by the clamp).
Surgical specimen (gossypiboma).
The possibility of a RFB should be in the differential diagnosis of any postoperative patient who presents with pain, infection, or palpable mass. The first diagnostic modality to rule out a RFB should be a CT scan and often it will be the only test needed. The CT findings of a sponge usually describe a rounded mass with a dense central part and an enhancing wall. Other features of retained sponges or towels include a whorl-like appearance with trapped air bubbles and cystic masses with infolded densities. MRI features can be confusing because the radiopaque marker is not magnetic or paramagnetic so is not visible.
Clinicians usually think that the diagnosis of a RFB on an intraoperative radiograph is easy and obvious, but often this is not the case. Intraoperative radiographs can be of poor quality, especially in obese patients. Correctly identifying a sponge on a radiograph can be difficult. The surgical markers may become twisted or folded and present an unusual image. For instance, in a report of 13 patients with a retained sponge, the radiopaque marker inside the sponge was seen in only 9 radiographs and even then was not immediately recognized for what it was. Markers have been misinterpreted as calcifications, intestinal contrast material, wires, or surgical clips.
The usual treatment of a RFB is removal. Reopening the previous operative site is one possibility, but endoscopic or laparoscopic approaches may be attempted.
One possible complication during surgical removal of RFB is perforation of adherent bowels, which may be missed. We had another case with retained two surgical towels during emergency cesarean section. Her surgeon removed the towels through a small incision. However, she was admitted in our service three days later with clinical picture of generalized peritonitis. Explorative laparotomy revealed a missed small bowel perforation.
In some instances the attempt to remove the retained foreign body may cause more harm than the item itself, although in these circumstances the foreign body is usually a needle or small part of a surgical item. In these cases, removal is not recommended. Rarely is this an appropriate course of action for a retained sponge, which should always be removed.
Recently, New England Journal of Medicine published an article about risk factors of RFBs. Of the 8 risk factors the authors identified (emergency operation, unexpected change in operation, more than one surgical team involved, change in nursing staff during procedure, body mass index (BMI), volume of blood loss, female sex, and surgical counts) only 3 were found to be statistically significant by multivariate logistic regression. The 3 significant risk factors were emergency surgery, unplanned change in the operation, and BMI. The counting of sponges and instruments was not a significant predictor in the multivariate model. Although all 3 factors were significant, the 9-fold increase in risk associated with emergency surgery was impressive. In addition, in 88% of the cases where there was a RFB and counts were performed, the counts were falsely called correct. The authors recommended "radiographic screening" at the end of high risk cases as a possible adjunct to improve detection of RFB. Surgeons should place radiologically detectable sponges and towels in the surgical site, carefully consider the use of small sponges in large cavities, and perform a methodical wound examination each and every time before they begin to close the wound.
New technologies are being developed that will hopefully decrease the incidence of RFB. An electronic article surveillance system has been examined which uses a tagged surgical sponge that can be identified electronically. Bar codes can be applied to all sponges, and with the use of a bar code scanner the sponges can be counted on the back table. The use of radiofrequency identification systems holds much hope for application in the area of detection of sponges.
In this case the complainant has stated that this sponge mass or cottonbody has been left in the body of her wife due to negligence of Sahara Hospital. The opposite parties had said that this was left during some other operation after the discharge from Sahara Hospital. Smt. Sumeena Tripathi was discharged from Sahara Hospital on 01.10.2013. As per opposite parties, the diagram drawn by a senior surgeon Dr Sablok very clearly show to surgical scars on her abdomen, a low transverse Cesarean scar and a vertical scar with an incisional hernia. We have seen this report which is on record. It would be better to scan the said diagram drawn with the prescription dated 25.03.2014.
Now in the above-mentioned description having a diagram it is clearly written that hernia.....Two years. It means that this hernia scar may be of two years back that is in the year 2012 or specifically can be said that it is of 25.03.2012. It means that when she was operated in Sahara Hospital on 01.10.13, this fact should have been mentioned by the doctors of Sahara Hospital. But there is nothing written by Sahara Hospital and now they are trying to take the advantages of the prescription dated 25.03.2014 but they failed to prove it that this hernia scar was after 01.10.2013 and before 25.03.2014. If there would be any cotton or sponge during the cesarean operation at Sahara Hospital, this fact should have been mentioned by the concerned Dr but as there is no mention of this fact, and later on it is found, the burden of proof will lie on the Sahara Hospital that it was left during any other operation after the discharge from Sahara Hospital in which they completely failed. CECT whole body of Smt. Samina Tripathi dated 06.07.2014 clearly establishes the fact of presence of foreign body in the body of Smt. Samina Tripathi. This report is very important and it is scan here for ready reference.
We have seen the discharge slip of Sahara Hospital. In that discharge the nothing abnormal has been written by the concerned Dr meaning thereby that at that time there was no foreign body of any previous operation. The discharge slip of the Sahara hospital is scanned here for showing that this discharge certificate does not carry any abnormal note by the concerned Dr Now we have seen the discharge slip of the Sachkhand Hospital which show the presence of foreign body in the abdomen of the Smt. Sumina Tripathi .
Now let us see the oath taken be a doctor before entering the nobel profession of the Medical World. As per guidelines of MCI, Every member should get it framed in his or her office it should never be violated in its letter and spirit.
"I solemnly pledge myself to consecrate my life to service of humanity.
Even under threat, I will not use my medical knowledge contrary to the laws of Humanity.
I will maintain the utmost respect for human life from the time of conception.
I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient.
I will practice my profession with conscience and dignity.
The health of my patient will be my first consideration.
I will respect the secrets which are confined in me.
I will give to my teachers the respect and gratitude which is their due.
I will maintain by all means in my power, the honour and noble traditions of medical profession.
I will treat my colleagues with all respect and dignity.
I shall abide by the code of medical ethics as enunciated in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002.
I make these promises solemnly, freely and upon my honour."
Whether this oath has been complied with properly by the doctor. We know that the human body is a very complex body. The doctor spent years to study the course of MBBS/MD/MS and any other specialised field. Despite of all the facts they should be cautious during treatment of a patient because it is the patient who paid them for their livelihood. There is a maxim res ipsa loquitur first it is applicable in his field where somebody show negligence during their profession or during the discharge of work.
The complexity of the human body and the uncertainty involved in the medical procedure are of such great magnitude that it is impossible for a Doctor to guarantee a successful result; and the only assurance that he can give, or can be understood to have given by implication is that he is possessed of 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 exercising his skills with reasonable competence. An ordinary physician or surgeon is not expected to be either a clodhopper or feckless practitioner of profession, as much as, he is not expected to be a paragon, combining qualities of polymath or prophet as in the realm of diagnosis and treatment, there is ample scope for genuine difference of opinion; and a Doctor cannot be treated as negligent merely because his conclusion differs from that of other persons in the profession, or because he has displayed less skill or knowledge than others would have shown. The true test for establishing negligence in diagnosis or treatment on the part of a doctor is whether he has been proved to be guilty of such failure as no doctor of ordinary skill would be guilty of, if acting with ordinary care. Furthermore, a golden principle of law has been laid down by the Hon'ble Apex Court in Jacob Mathew Vs. State of Punjab, (AIR 2005 SC 3180) that no sensible professional would intentionally commit an act or omission which would result in loss or injury to the patient as the professional reputation of the person is at stake. A single failure may cost him dear in his career. Even in civil jurisdiction, the rule of res ipsa loquitor is not an 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 doctor cannot be held liable per-se by applying the doctrine of res ipsa loquitor. Yet, another golden principle of law has been laid down by the Hon'ble Apex Court in Indian Medical Association Vs. V.P. Santha's III (1995) CPJ 1 (SC) at para 37 that "it is no doubt true that sometimes complicated questions requiring recording of evidence of experts may arise in a complaint about deficiency in service based on the ground of negligence in rendering medical services by a medical practitioner; but this would not be so in all complaints about deficiency rendering services by a medical practitioner. There may be cases which do not raise such complicated questions and the deficiency in service may be due to obvious faults which can be easily established such as removal of the wrong limb or the performance of an operation on the wrong patient or giving injection of a drug to which the patient is allergic without looking into the out patient card containing the warning or use of wrong gas during the course of an anaesthetic or leaving inside the patient swabs or other items of operating equipment after surgery. Furthermore, it has been observed in Malay Kumar Ganguli's case (AIR 2010 SC 1162) that" charge of professional negligence on a medical person is a serious one as it affects his professional statusand reputation and as such, the burden of proof would be more onerous. A doctor cannot be held negligent only because something has gone wrong. He also cannot be held liable for mischance or misadventure or for an error in judgment in making a choice when two options are available. The mistake in diagnosis is not necessarily a negligent diagnosis." In the instant matter, thus a simple test, in the light of aforesaid observations, needs to be conducted in order to ascertain whether the Doctor is guilty of any tortious act of negligence/battery amounting to deficiency in conducting a surgery in the delivery of child and not properly attending the patient, the complainant and consequently, liable to pay damages for leaving cotton mass in the abdomen / stomach due to failure in surgery and deteriorating condition of the patient.
Now, it is required to be seen whether an expert report is necessary in each and every case relating to medical negligence or not ? It has been observed by the Hon'ble Apex Court in Indian Medical Association Vs. V.P. SanthaIII(1995) CPJ 1 (SC) at para 37 that "it is no doubt true that sometimes complicated questions requiring recording of evidence of experts may arise in a complaint about deficiency in service based on the ground of negligence in rendering medical services by a medical practitioner; but this would not be so in all complaints about deficiency rendering services by a medical practitioner. There may be cases which do not raise such complicated questions and the deficiency in service may be due to obvious faults which can be easily established such as removal of the wrong limb or the performance of an operation on the wrong patient or giving injection of a drug to which the patient is allergic without looking into the out patient card containing the warning or use of wrong gas during the course of an anaesthetic or leaving inside the patient swabs or other items of operating equipment after surgery. Furthermore, in B. Krishna Rao Vs. Nikhil Super Speciality Hospital 2010 (V) SCC513 at para 40 the Hon'ble Apex Court was pleased to hold that it is not necessary to have opinion of the expert in each and every case of medical negligence. The Hon'ble Apex Court was pleased to further hold in Nizam Institute of Medical Sciences Vs. Prashant S. Dhananka and others 2009 (VI) SCC 1 that "in a case of medical negligence, once initial burden has been discharged by the complainant by making of a case of negligence on the part of the hospital or the doctor concerned, the owner then shifts on the hospital or to the attending doctors and it is for the hospital to satisfy the court that there was no lack of care or diligence".
A doctrine or rule of evidence in tort law that permits an inference or presumption that a defendant was negligent in an accident injuring the plaintiff on the basis of circumstantial evidence if the accident was of a kind that does not ordinarily occur in the absence of negligencea plaintiff who establishes the elements of res ipsa loquitur can withstand a motion for summary judgment and reach the jury without direct proof of negligence-- Cox v. May Dept. Store Co., 903 P.2d 1119 (1995).
In Byrne vs Boadle, this maxim was used for the first time where the complainant was injured by a barrel that dropped from the window of the defendant. In the abovementioned case, Pollock, C. B., said "here are many incidents from which no presumption of negligence can arise, but this is not true in every case. It is the duty of persons who keep barrels in a warehouse to take care that they do not roll out and I think that such a case will, beyond all doubt, afford prima facie proof of negligence."
This doctrine intends to help direct the court proceedings to a conclusion, especially if it is established through the implication of this doctrine's rule that the injury caused to the claimant would not have occurred or taken place if the defendant wasn't negligent.This also gives enough cause and evidence to hold the defendant liable for his negligent actions.
Essentials of Res Ipsa Loquitur Maxim The injury caused to the plaintiff shall be a result of an act of negligence.
There is a lack of evidence, or the evidence presented before the court is insufficient to establish the possibilities of the fault of the plaintiff or third party.
The defendant owes a duty of care towards the plaintiff, which he has breached.
There is a significant degree of injury caused to the plaintiff.
Applicability of Doctrine of Res Ipsa Loquitur The maxim of res ipsa loquitur came into force to benefit the plaintiff as he can use circumstantial evidence to establish negligence.
Consequently, it shifts the burden of proof on the defendant, logic being, where there is an event of unexplained cause, usually, the one that does not occur without the defendant's negligence in controlling the action which has caused the injury to the claimant or destroyed his goods.
In this scenario, the court shall presume negligence on the part of the defendant in such a case unless it includes an appropriate explanation compatible with his taking reasonable care.
In Achutrao Haribhau Khodwa and Others vs State of Maharashtra and Others, it was considered that the maxim should not be applied in the case of general incidences of neglect and shall only be reflected when there is a significant degree of injury caused.
Section 106 of the Indian Evidence Act Section 106 of the Act provides that when any fact is especially within the knowledge of any person, the burden of proving that fact is upon him.
Res ipsa loquitur is a Latin phrase that means "the thing speaks for itself." In personal injury law, the concept of res ipsa loquitur (or just "res ipsa" for short) operates as an evidentiary rule that allows plaintiffs to establish a rebuttable presumption of negligence on the part of the defendant through the use of circumstantial evidence.
This means that while plaintiffs typically have to prove that the defendant acted with a negligent state of mind, through res ipsa loquitur, if the plaintiff puts forth certain circumstantial facts, it becomes the defendant's burden to prove he or she was not negligent.
Res Ipsa Loquitur and Evidence Law Accidents happen all the time, and the mere fact that an accident has occurred doesn't necessarily mean that someone's negligence caused it. In order to prove negligence in a personal injury lawsuit, a plaintiff must present evidence to demonstrate that the defendant's negligence resulted in the plaintiff's injury. Sometimes, direct evidence of the defendant's negligence doesn't exist, but plaintiffs can still use circumstantial evidence in order to establish negligence.
Circumstantial evidence consists of facts that point to negligence as a logical conclusion rather than demonstrating it outright. This allows judges and juries to infer negligence based on the totality of the circumstances and the shared knowledge that arises out of human experience. Res ipsa is one type of circumstantial evidence that allows a reasonable fact finder to determine that the defendant's negligence caused an unusual event that subsequently caused injury to the plaintiff.
This doctrine arose out of a case where the plaintiff suffered injuries from a falling barrel of flour while walking by a warehouse. At the trial, the plaintiff's attorney argued that the facts spoke for themselves and demonstrated the warehouse's negligence since no other explanation could account for the cause of the plaintiff's injuries.
As it has developed since then, res ipsa allows judges and juries to apply common sense to a situation in order to determine whether or not the defendant acted negligently.
Since the laws of personal injury and evidence are determined at the state level, the law regarding res ipsa loquitur varies slightly between states. That said, a general consensus has emerged, and most states follow one basic formulation of res ipsa.
Under this model for res ipsa, there are three requirements that the plaintiff must meet before a jury can infer that the defendant's negligence caused the harm in question:
The event doesn't normally occur unless someone has acted negligently;
The evidence rules out the possibility that the actions of the plaintiff or a third party caused the injury; and The type of negligence in question falls with the scope of the defendant's duty to the plaintiff.
As mentioned above, not all accidents occur because of someone else's negligence. Some accidents, on the other hand, almost never occur unless someone has acted negligently.
Going back to the old case of the falling flour-barrel, it's a piece of shared human knowledge that things don't generally fall out of warehouse windows unless someone hasn't taken care to block the window or hasn't ensured that items on the warehouse floor are properly stored. When something does fall out of a warehouse window, the law will assume that it happened because someone was negligent.
Top of Form Bottom of Form The second component of a res ipsa case hinges on whether the defendant carries sole responsibility for the injury. If the plaintiff can't prove by a preponderance of the evidence that the defendant's negligence cause the injury, then they will not be able to recover under res ipsa.
States sometimes examine whether the defendant had exclusive control over the specific instrumentality that caused the accident in order to determine if the defendant's negligence caused the injury. For example, if a surgeon leaves a sponge inside the body of a patient, a jury can infer that the surgeon's negligence caused the injury since he had exclusive control over the sponges during the operation.
In addition to the first two elements, the defendant must also owe a duty of care to protect the plaintiff from the type of injury at issue in the suit. If the defendant does not have such a duty, or if the type of injury doesn't fall within the scope of that duty, then there is no liability.
For example, in many states, landowners don't owe trespassers any duty to protect them against certain types of dangers on their property. Thus, even if a trespasser suffers an injury that was caused by the defendant's action or inaction and that wouldn't normally occur in the absence of negligence, res ipsa loquitur won't establish negligence since the landowner never had any responsibility to prevent injury to the trespasser in the first place.
Res ipsa only allows plaintiffs to establish the inference of the defendant's negligence, not to prove the negligence completely. Defendants can still rebut the presumption of negligence that res ipsa creates by refuting one of the elements listed above.
For example, the defendant could prove by a preponderance of the evidence that the injury could occur even if reasonable care took place to prevent it. An earthquake could shake an item loose and it could fall out of the warehouse window, for instance.
A defendant could also demonstrate that the plaintiff's own negligence contributed to the injury. To go back to the flour-barrel example, if the defendant shows that the plaintiff was standing in an area marked as dangerous it could rebut the presumption of negligence created by res ipsa.
Finally, the defendant could establish that he did not owe the plaintiff a duty of care under the law, or that the injury did not fall within the scope of the duty owed. For example, if the law only imposes a limited duty on the defendant not to behave recklessly, then res ipsa will not help the plaintiff by creating an inference of negligence since a negligent action would not violate the duty owed to the plaintiff.
According to the Blacks Law Dictionary the maxim is defined as the doctrine providing that, in some circumstances, the mere fact of accidents occurrence raises an inference of negligence so as to establish a prima facie (at first sight) case. It is a symbol for that rule that the fact of the occurrence of an injury taken with the surrounding circumstances may permit an inference or recipes omission of negligence, or make out a plaintiff's prima facie case and present a question of fact for defendant to meet with and explanation. It is merely a short way of saying that the circumstances attendant on the accident are of such a nature to justify a jury in light of common sense and past experience in inferring that the accident was probably the result of the defendant's negligence, in the absence of explanation or other evidence which the jury believes.
Its use in clinical negligence gained some traction before Bolam and Bolitho. Mahon v Osborne [1939] 1 All ER 535, is an early example of the application of res ipsa loquitur in a case where a surgical swab had been left inside a patient's body.
In Clarke v Worboys (1952) Times, 18 March, CA, a patient noticed burns on her buttock shortly after surgical excision of a breast tumour. The surgery involved cauterisation. The Court of Appeal held that this was a case where res ipsaloquitur applied. The outcome was not one that would ordinarily occur in the absence of negligence, and the surgical team were unable to explain how the injury was caused.
In Cassidy v Ministry of Health [1951] 2 KB 343, Denning LJ succinctly summarised the maxim's application to clinical negligence.
cases: "I went into hospital to be cured of two stiff fingers. I have come out with four stiff fingers and my hand is useless. That should not happen if due care had been used. Explain it if you can."
Ng Chun Pui Vs Lee Chuen Tat, the first defendant was driving a coach owned by the second defendant westwards in the outer lane of dual carriageway in Hong Kong. Suddenly the course across the central reservation and collided with a public bus travelling in the inner lane of the other carriageway, killing one passenger in the bus and injuring the driver and three others on the bus. The plaintiff could not prove that the defendants were negligent and had caused the accident. They however proceeded on the basis of Res Ipsa Loquitur and shifted the onus on the defendants to prove that they were not negligent. However, they failed to do so. And the judicial committee of the Privy Council held the defendants liable for the plaintiffs injuries. { MarkLuneyand Ken Opliphant , Tort Law Text And Materials (Oxford University Press, New York, 2000) pp 173-175 } In A.S. Mittal &Anr Vs State Of UP &Ors , AIR 1979 SC 1570 , the defendants had organised an eye camp at Khurja along with the Lions Club. 88 low risk cataract operations were undertaken during the period of the camp. It was however, disastrous as many of those who had been operated upon lost their eyesight due to post medical treatment. Proceedings against the government initiated for negligence of the doctors. Damages worth ₹ 12,500/- were paid as interim belief to each of the aggrieved. The decision was on the basis of Res Ipsa Loquitur as the injury would not have occurred had the doctors not been negligent in not having followed up with post-operation treatment. Res Ipsa Loquitur can be applied in matters where are the procedures have not been followed and is not just limited to the commission of an act.
We can define 'Medical negligence' as the improper or unskilled treatment of a patient by a medical practitioner. This includes negligence in taking care from a nurse, physician, surgeon, pharmacist, or any other medical practitioner. Medical negligence leads to 'Medical malpractices' where the victims suffer some sort of injury from the treatment given by a doctor or any other medical practitioner or health care professional.
Medical negligence can occur in different ways. Generally, it occurs when a medical professional deviates from the standard of care that is required.
So, we can say that any kind of deviation from the accepted standards of medication and care is considered to be medical negligence and if it causes injury to a patient then the doctor who operated on him, other staff and/or hospital may be held liable for this.
Some of the common categories of medical negligence are as follows:
Wrong diagnosis - When someone goes to a hospital, clinic or medical room, etc. the first step after admittance is the diagnosis. Diagnosing symptoms correctly is critical and important to provide medical care to any patient. However, if a patient is not treated properly due to any mistake in diagnosis, the doctor can be made liable for any further injury or damages caused as a result of the wrong diagnosis.
Delay in diagnosis - A delayed diagnosis is treated as medical negligence if another doctor would have reasonably diagnosed the same condition in a timely fashion. A delay in diagnosis can cause undue injury to the patient if the illness or injury is left to worsen with time rather than being treated. Obviously, any delay in the identification and treatment of an injury can reduce the chance of recovery for the patient.
Error in surgery - Surgical operations require an enormous level of skill and it should be done with due care and caution because even the slightest mistakes can have profound effects on the patient. The wrong-site surgery, lacerations of any internal organ, severe blood loss, or a foreign object being left in the body of the patients, all this comes under Surgical error.
Unnecessary surgery - Unnecessary surgery is usually associated with the misdiagnosis of patient symptoms or a medical decision without proper consideration of other options or risks. Alternatively, sometimes surgery is chosen over conventional treatments for their expediency and ease compared to other alternatives.
Errors in the administration of anesthesia - Anesthesia is a risky part of any major medical operation and requires a specialist (anesthesiologist) to administer and monitor its effect on the patient. Prior to any medical procedure requiring anesthesia, the anesthesiologist has to review the patient's condition, history, medications, etc. to determine the most suitable of all the medicine to use. Anesthesia malpractice can happen even during the pre-operation medical review or during the procedure itself.
Childbirth and labor malpractice - Childbirth is a difficult event for a woman and it becomes worse if not handled properly by the doctors and nurses. There are many instances of medical negligence during childbirth including the mishandling of a difficult birth, complications with induced labor, misdiagnosis of a newborn medical condition, etc. Long-Term negligent treatment - Medical negligence can also occur in subtle ways over the course of a long treatment period. Usually, the negligence can take the shape of a failure to follow up with treatment, or a doctor's failure to monitor the effects of the treatment properly.
A standard of care specifies the appropriate treatment and medication procedure as per the requirements that should be taken into account by a doctor while providing the treatment to his patients. The care should not be of the highest degree nor the lowest.Here, the degree means the level of care an ordinary health care professional, with the same training and experience, would render in similar circumstances in the same community. This is the critical question in medical malpractice cases and if the answer is "no," and you suffered injury as a result of the poor treatment, you may file a suit for medical malpractice.
In the case of Dr. Laxman Balkrishna Joshi Vs. Dr. TrimbakBapu Godbole and Anr.[ 1969 AIR 128], the Supreme Court held that a doctor has certain aforesaid duties and a breach of any of those duties can make him liable for medical negligence. A doctor is required to exercise a reasonable degree of care that is set for this profession.
Dr. Kunal Saha vs Dr. Sukumar Mukherjee on 21 October, 2011 ( NC) original petition number 240 OF 1999 is one of the most important case regarding medical negligence. The brief facts of the case are-
"Toxic Epidermal Necrolysis (TEN) is a rare and deadly disease. It is an extoliative dermatological disorder of unknown cause. A patient with TEN loses epidermis in sheet-like fashion leaving extensive areas or denuded dermis that must be treated like a larze, superficial, partial-thickness burn wound. The incidence of TEN has been reported at 1 to 1.3 per million per year. The female-male ratio is 3:2. TEN accounts for nearly 1% of drug reactions that require hospitalization. TEN has a mortality rate of 25 to 70%.
Smt. Anuradha Saha (in short Anuradha), aged about 36 years wife of Dr. Kunal Saha (complainant) became the unfortunate victim of TEN when she alongwith the complainant was in India for a holiday during April-May 1998. She and the complainant although of Indian original were settled in the United States of America. The complainant is a doctor by profession and was engaged in research on HIV / AIDS for the past fifteen years. Anuradha after acquiring her Graduation and Masters Degree was pursuing a Ph.D. programme in a university of U.S.A. She was a Child Psychologist by profession. Anuradha showed certain symptoms of rashes over her body and received treatment at the hands of Opposite Parties and some other doctors as outdoor patient uptil 10.05.1998 and she was admitted in Advanced Medicare and Research Institute Limited, Calcutta (for short, AMRI), on 11.05.1998, where she was treated by the above-named Opposite Parties and other doctors uptil 16.05.1998. As there was no improvement in her condition, she was shifted to Breach Candy Hospital, Mumbai, on 17.05.1998 by an air ambulance. She was treated in Breach Candy Hospital from 17.05.1998 evening till she breathed her last on 28.05.1998.
Our Complainant as husband of Anuradha felt that the doctors who treated Anuradha and the hospitals where she was treated were grossly negligent in her treatment and her death was occasioned due to gross negligence of the treating doctors and hospitals. Complainant, accordingly, got issued a legal notice to as many as 26 persons i.e. various doctors who treated Anuradha between end of April to the date of her death alleging negligence and deficiency in service on their part and claiming a total compensation exceeding Rs.55 crores from them. Complainant, thereafter filed the present complaint on 09.03.1999 before this Commission claiming a total compensation of Rs. Rs.77,07,45,000/- ( Seventy Seven Crores Seven Lakhs Fourty Five Thousand only). Later he also filed another complaint no. 179 of 2000 in this Commission against Breach Candy Hospital, its doctors and functionaries claiming a further compensation of Rs.25.30 crore ( though the said complaint was later on withdrawn), thereby making claim of compensation exceeding Rs.102 crores, perhaps the highest ever claimed by any complainant for medical negligence before any consumer fora established under the provisions of Consumer Protection Act, 1986 ( in short, the Act). These are some of the facts which make the present case extra ordinary.
The present complaint was filed by the complainant against the above-named opposite parties, namely, Dr. Sukumar Mukherjee, Dr. B. Haldar (Baidyanath Halder), Advanced Medicare and Research Institute Limited ( in short the AMRI Hospital ) and Dr. Balram Prasad and Dr.Abani Roy Chowdhury (physician) and Dr.KaushikNandy (plastic surgeon), the Directors of the AMRI Hospital and others claiming a total compensation of Rs. Rs.77,07,45,000/- under different heads alleging various acts of commission and omission on the part of the doctors and hospital amounting to negligence and deficiency in service. Complainant through his brother-in-law Malay Kumar Ganguly also filed criminal complaint against some of the doctors and the hospital under section 304A IPC.
The complaint was resisted by the doctors and the hospital on a variety of grounds thereby denying any medical negligence or deficiency in service on their part. Parties led voluminous documentary and oral evidence and testimonies of some of the witness were even recorded through video conferencing through a Local Commissioner. After a protracted trial and hearing and on consideration of the evidence and material so produced on record and taking note of the legal position governing the question of medical negligence, this Commission ( by a three Member Bench presided over by the then President) dismissed the complaint by an order dated 01.06.2006 holding as under:
In the result, we reiterate that Doctors or Surgeons do not undertake that they will positively cure a patient. There may be occasions beyond the control of the medical practitioner to cure the patients. From the record, it would be difficult to arrive at the conclusion that the injection Depo-Medrol prescribed by Dr. Mukherjee was of such excessive dose that it would amount to deficiency in service by him which was his clinical assessment.
Thereafter, with regard to the alleged deficiency in the treatment given to Mrs. Anuradha by Opposite Party Doctors 2, 3, 5 and 6, there is no substance. The contention against the hospital that it was not having Burns-Ward, and therefore, the deceased suffered is also without substance. Hence, this complaint is dismissed. There shall be no order as to costs.
Aggrieved by the dismissal of his complaint, the complainant filed Civil Appeal (No. 1727 of 2007) in the Honble Supreme Court. It would appear that even before the said appeal was filed before the Honble Supreme Court, the Supreme Court was seized of the matter in Criminal Appeal Nos. 1191-94 of 2005 filed by Malay Kumar Ganguly, the complainant in the criminal complaint, against the Orders passed by the Calcutta High Court. Since the Criminal Appeals and the Civil Appeal filed by the complainant in the present complaint raised the same questions of fact and law, the Honble Supreme Court heard all the appeals together and decided the same by means of a detailed judgment dated 07.8.2009. By the said order, the Apex Court dismissed the Criminal Appeals filed by Shri Malay Kumar Ganguly but allowed the Civil Appeal No. 1727 of 2007 filed by the complainant and set aside the order dated 01.6.2006 passed by this Commission dismissing the complaint and remanded the matter to this Commission for the limited purpose of determining the adequate compensation, which the complainant is entitled to receive from the subsisting opposite parties by observing as under:
So far as the judgment of the Commission is concerned, it was clearly wrong in opining that there was no negligence on the part of the Hospital or the doctors. We, are, however, of the opinion, keeping in view the fact that Dr.KaushikNandy has done whatever was possible to be done and his line of treatment meets with the treatment protocol of one of the experts viz.. Prof. Jean Claude Roujeau although there may be otherwise difference of opinion, that he cannot be held to be guilty of negligence.
We remit the case back to the Commission only for the purpose of determination of the quantum of compensation.
We, keeping in view the stand taken and conduct of AMRI and Dr. Mukherjee, direct that costs of Rs.5,00,000 and Rs.1,00,000 would be payable by AMRI and Dr. Mukherjee respectively.
We further direct that if any foreign experts are to be examined it shall be done only through video conferencing and at the cost of the respondents.
Summary In view of the foregoing discussion, we conclude as under:
The facts of this case viz., residence of the complainant and Anuradha (deceased) in USA and they working for gain in that country; Anuradha having been a victim of a rare and deadly disease Toxic Epidermal Necrolysis (TEN) when she was in India during April-May 1998 and could not be cured of the said disease despite her treatment at two superspeciality medical centres of Kolkata and Mumbai and the huge claim of compensation exceeding Rs.77 crores made by the complainant for the medical negligence in the treatment of Anuradha makes the present case somewhat extraordinary.
The findings given and observations made by the Supreme Court in its judgment dated 07.08.2009 are absolutely binding on this Commission not only as ratio decidendi but also as as obiter dicta also, the judgment having been rendered by the Supreme Court in appeal against the earlier order passed by a three Member Bench of this Commission and, therefore, no attempt can be allowed to read down / dilute the findings and observations made by the Supreme Court because the Supreme Court has remitted the complaint to this Commission only for the purpose of determination of the quantum of compensation after recording the finding of medical negligence against the opposite parties and others.
The task entrusted to the Commission may appear to be simple but the facts of the present case and the voluminous evidence led on behalf of the complainant has made it somewhat arduous. Still difficult was the task of apprortionment of the liability to pay the awarded amount by the different opposite parties and perhaps it was for this reason that the Supreme Court has remitted the matter to this Commission.
Multiplier method provided under the Motor Vehicles Act for calculating the compensation is the only proper and scientific method for determination of compensation even in the cases where death of the patient has been occasioned due to medical negligence / deficiency in service in the treatment of the patient, as there is no difference in legal theory between a patient dying through medical negligence and the victim dying in industrial or motor accident. The award of lumpsum compensation in cases of medical negligence has a great element of arbitrariness and subjectivity.
The foreign residence of the complainant or the patient and the income of the deceased patient in a foreign country are relevant factors but the compensation awarded by Indian Fora cannot be at par which are ordinarily granted by foreign courts in such cases. Socio economic conditions prevalent in this country and that of the opposite parties / defendants are relevant and must be taken into consideration so as to modulate the relief. A complainant cannot be allowed to get undue enrichment by making a fortune out of a misfortune. The theoretical opinion / assessment made by a Foreign Expert as to the future income of a person and situation prevalent in that country cannot form a sound basis for determination of future income of such person and the Commission has to work out the income of the deceased having regard to her last income and future prospects in terms of the criteria laid down by the Supreme Court.
There exists no straight jacket formula for apportionment of the awarded compensation amongst various doctors and hospitals when there are so many actors who are responsible for negligence and the apportionment has to be made by evolving a criteria / formula which is just going by the nature and extent of medical negligence and deficiency in service established on the part of different doctors and hospitals.
On a consideration of the entirety of the facts and circumstances, evidence and material brought on record, we hold that overall compensation on account of pecuniary and non pecuniary damages works out to Rs.1,72,87,500/- in the present case, out of which we must deduct 10% amount on account of the contributory negligence / interference of the complainant in the treatment of Anuradha. That will make the net payable amount of compensation to Rs.1,55,58,750/- (rounded ofto Rs.1,55,60,000/-). From this amount, we must further deduct a sum of Rs.25,93,000/- which was payable by Dr. Abani Roy Chowdhury (deceased) or his Legal Representative as the complainant has forgone the claim against them.
In view of the peculiar facts and circumstances of the case and as a special case, we have awarded a sum of Rs. 5,00,000/- as cost of litigation in the present proceedings.
The above amount shall be paid by opposite parties no. 1 to 4 to the complainant in the following manner:
(i). Dr. Sukumar Mukherjee-opposite party no.1 shall pay a sum of Rs.40,40,000/- (Rupees Forty Lakh Forty Thousand only) i.e. [Rs.38,90,000/- towards compensation and Rs.1,50,000/- as cost of litigation] .
(ii) Dr. B. Haldar (Baidyanth Halder)-opposite party no.2 shall pay a sum of Rs.26,93,000/- (Rupees Twenty Six Lakh Ninety Three Thousand only) i.e. [Rs.25,93,000/- towards compensation and Rs.1,00,000/- as cost of litigation]
(iii) AMRI hospital-opposite party no.3 shall pay a sum of Rs.40,40,000/- (Rupees Forty Lakh Forty Thousand only ) i.e. [Rs.38,90,000/- towards compensation and Rs.1,50,000/- as cost of litigation]
(iv) Dr. Balram Prasad-opposite party no.4 shall pay a sum of Rs.26,93,000/- (Rupees Twenty Six Lakh Ninety Three Thousand only) i.e. [Rs.25,93,000/- towards compensation and Rs.1,00,000/- as cost of litigation] The opposite parties are directed to pay the aforesaid amounts to the complainant within a period of eight weeks from the date of this order, failing which the amount shall carry interest @ 12% p.a. w.e.f. the date of default. "
Now we again come to the facts of this case. We have seen the report of Spiral (Helical) CT Study of Abdominof MrsSumena Tripathi dtd 25.10.14 in which the following impressions are revealed :
"Cholelithiasis with Few Enlarged Periportal Lymph Nodes".
"Focal Small Bowel Wall Thickening in Right Upper Quadrant Reason with Mild Ascites".
Again the ultrasound study of whole Abdominof MrsSumena Tripathi dtd 25.10.14 says "Contractd GB with Cholelithiasis" and "minimal ascites".
Now we have to see what isContractd GB with Cholelithiasis?
A contracted gallbladder is a medical condition in which the gallbladder becomes smaller and harder. This condition is also known as gallbladder atrophy. This can happen for several reasons, but most often it is due to the build-up of cholesterol and other fatty deposits on the gallbladder walls.Typically, a collapsed gallbladder results from stone disease or some other obstruction, with gallstones being a common reason for inflammation in the gallbladder. Risk factors for cholelithiasis, which may causeTrusted Source a chronically collapsed gallbladder, include:
being female having obesity having had rapid weight loss being pregnant being over the age of 60 years eating a diet high in fat Additional risk factors for a collapsed gallbladder include:
family history of gallstones birth control pills, such as levonorgestrel, may increase the riskTrusted Source of gallbladder disease high dose estrogen therapy hormone replacement therapy Objective In this article we present a simplified algorithm-based approach to the thickening of the small and large bowel wall detected on routine computed tomography (CT) of the abdomen.
Background Thickening of the small or large bowel wall may be caused by neoplastic, inflammatory, infectious, or ischaemic conditions. First, distinction should be made between focal and segmental or diffuse wall thickening. In cases of focal thickening further analysis of the wall symmetry and perienteric anomalies allows distinguishing between neoplasms and inflammatory conditions. In cases of segmental or diffuse thickening, the pattern of attenuation in light of clinical findings helps narrowing the differential diagnosis.
Conclusion Focal bowel wall thickening may be caused by tumours or inflammatory conditions. Bowel tumours may appear as either regular and symmetric or irregular or asymmetric thickening. When fat stranding is disproportionately more severe than the degree of wall thickening, inflammatory conditions are more likely. With the exception of lymphoma, segmental or diffuse wall thickening is usually caused by benign conditions, such as ischaemic, infectious and inflammatory diseases.
Key points • Thickening of the bowel wall may be focal (<5 cm) and segmental or diffuse (6-40 cm or >40 cm) in extension.
• Focal, irregular and asymmetrical thickening of the bowel wall suggests a malignancy.
• Perienteric fat stranding disproportionally more severe than the degree of wall thickening suggests an inflammatory condition.
• Regular, symmetric and homogeneous wall thickening is more frequently due to benign conditions, but can also be caused by neoplasms such as well-differentiated adenocarcinoma and lymphoma.
• Segmental or diffuse bowel wall thickening is usually caused by ischaemic, inflammatory or infectious conditions and the attenuation pattern is helpful in narrowing the differential diagnosis.
Keywords: Computed tomography, Inflammatory bowel disease, Small bowel intestinal neoplasms Introduction With the development of multidetector computed tomography scanners (MDCT), computed tomography became an important tool in the detection and characterisation of bowel abnormalities. This technology makes possible the acquisition of isotropic data and affords the capability of performing high-resolution multiplanar reconstructions [1-6]. In particular, CT enterography acquired after luminal distention through the administration of high volumes of neutral contrast material (,1500-2,000 ml of water, water-methylcellulose solution, polyethylene glycol electrolyte solution or low-concentration barium) is helpful in displaying the thickness and mural enhancement of the small bowel wall [2]. Adequate preparation and distention of the bowel lumen is, however, not always possible in the acute setting. In addition, wall abnormalities of the small and large bowel may be incidentally detected in asymptomatic patients or in patients with nonspecific complaints. For these, the CT imaging technique applied in a significant proportion of patients is a conventional one and radiologists should have a high level of suspicion in the detection and interpretation of bowel wall abnormalities.
Normal bowel wall Acceptable bowel wall thickness values on CT strongly depend on the degree of bowel distension and vary widely in the literature. Some agreement, however, exists that the small bowel wall should not exceed 3 mm despite luminal distention, and the colonic wall can vary from 1 to 2 mm when the lumen is well distended to 5 mm when the wall is contracted or the lumen is collapsed [2-9].
The bowel wall normally enhances after the administration of intravenous contrast material. The mucosa is the most intensely enhancing layer of the bowel wall and when enhanced may appear as a distinct layer. In contrast, the submucosa is less vascularised and is seldom seen as a separate structure on CT scans unless it is oedematous, haemorrhagic or infiltrated by fat [10].
Thickening of the bowel wall Thickening of the bowel wall may be caused by several pathologic conditions or be a normal variant [4]. When thickening of the bowel wall is identified on CT, several imaging features must be assessed in order to narrow the differential diagnosis: length of involvement, degree of thickening, symmetric versus asymmetric involvement, pattern of attenuation and perienteric abnormalities [3, 4, 6]. Each of these features may have a different significance according to the acute or chronic onset of clinical symptoms and will be further discussed in an algorithm approach [6].
Approach to the thickened bowel wall When thickening of the small or large bowel wall is identified on CT, the first step to take is to access the extent of the involved bowel. Distinction should be made between (1) focal (less than 5 cm of extension) and (2) segmental (6-40 cm) or diffuse (>40 cm) involvement [3]. This is an important step in differentiating between benign and malignant causes of bowel wall thickening: while most bowel tumours present as a focal involvement, segmental and diffuse thickening of the bowel wall are usually caused by benign conditions [10]. The exception is a small bowel lymphoma, which typically shows as a segmental distribution [3, 6] (Fig. 1).
Fig. 1 Algorithm approach to the bowel wall thickening. CD Crohn's disease, TB tuberculosis, IBD inflammatory bowel disease, RE radiation enteritis. Adapted from the electronic poster "Bowel wall thickening--a complex subject made simple" DOI:10.5444/esgar2011/EE-063 Focal thickening of the bowel wall Thickening of the bowel wall is considered focal when it extends less than 5 cm [3, 11]. Focal thickening may be caused by tumours or by inflammatory conditions, and distinguishing between the two conditions should be attempted. In addition to the clinical presentation, analysis of the wall symmetry, degree of thickening and perienteric abnormalities provides additional information for the correct diagnosis. In the setting of focal wall thickening three main scenarios may occur: (1) asymmetric focal thickening, (2) symmetric focal thickening and (3) perienteric abnormalities (fat stranding) disproportionately greater than the degree of wall thickening.
(1) Asymmetric focal thickening of the bowel wall Asymmetric thickening of the bowel wall corresponds to different degrees of eccentric thickening around the circumference of the involved segment and is typically caused by neoplasms [3, 12]. Malignant tumours of the gastrointestinal tract are more common in the stomach and colon and are less frequent in the small bowel, where they tend to occur at the proximal segments [11]. Neoplasms have a chronic onset and may present as an eccentric focal mass or, more commonly, as a circumferential asymmetric thickening, usually greater than 3 cm in thickness [3, 4, 10, 11, 13] (Fig. 2).
Fig. 2 Colon cancer. Axial contrast-enhanced CT scan shows focal asymmetric and irregular thickening of the ascending colon (arrow), a finding strongly suggestive of a neoplasm. Also note mild pericolonic fat stranding (asterisks), a frequent associated finding. Adapted from the electronic poster "Bowel wall thickening--a complex subject made simple" DOI:10.5444/esgar2011/EE-063 In this setting the attenuation pattern of the bowel wall after intravenous contrast administration and the perienteric abnormalities may be helpful in establishing the diagnosis. Contrast enhancement of malignant bowel tumours is frequently heterogeneous with areas of low attenuation due to ischaemia and necrosis [4, 10, 11]. This is particularly common on large and high-grade poorly differentiated tumours such as adenocarcinoma and stromal cell tumours [4]. In addition, regional adenopathy and distant metastases, when present, support the diagnosis [11].
Exceptions Although asymmetric and heterogeneous focal thickening of the bowel wall usually indicates a malignancy, benign inflammatory conditions such as intestinal tuberculosis and Crohn's disease may present with similar imaging features, sometimes mimicking neoplasms [3, 14, 15].
Gastrointestinal tuberculosis is rare. When present, however, it often involves the ileocaecal region. The inflammatory reaction usually produces eccentric wall thickening or a mass-like lesion. Discontinuous areas of mural thickening with associated luminal narrowing in the small bowel are also common and in combination with ileocaecal involvement should suggest the diagnosis. Large perienteric lymph nodes of low attenuation due to caseous necrosis are also common and characteristic (Fig. 3). These are not common in Crohn's disease and would be unusual for caecal carcinoma [15, 16].
Fig. 3 Intestinal tuberculosis. Axial (a) and reformatted coronal (b) contrast-enhanced CT scans show parietal irregular and asymmetric thickening of the caecum (large arrows), an appearance that mimics colon cancer. Also note low attenuation adenopathy (thin arrows), a usual finding in tuberculosis. Mild pericolonic fat stranding is also seen. Adapted from the electronic poster "Bowel wall thickening--a complex subject made simple" DOI:10.5444/esgar2011/EE-063 In addition, thoracic features of tuberculosis and other abdominal signs of involvement such as findings of peritonitis and hepatosplenic dissemination support the diagnosis.
Crohn's disease typically involves the right colon and the terminal ileum. Wall thickening in Crohn's disease is usually eccentric or asymmetric because of preferential involvement along the mesenteric border of the bowel wall [2, 7] (Fig. 4). Imaging features suggesting this diagnosis include the discontinuous involvement of the bowel wall ("skip areas"), signs of transmural inflammation such as fistulas and abscesses, and proliferation of the fat along the mesenteric border of the bowel [2, 3, 7].
Fig. 4 Crohn's disease mimicking colon cancer. Reformatted coronal (a) and axial (b) unenhanced CT scans and axial contrast-enhanced CT scan (c) show spiculated irregular wall thickening of the caecal wall (arrow in a-c) with heterogeneous contrast enhancement (c). Also note proliferation of the pericaecal fat (asterisk), a common finding in Crohn's disease. Adapted from the electronic poster "Bowel wall thickening--a complex subject made simple" DOI:10.5444/esgar2011/EE-063 (2) Symmetric focal thickening of the bowel wall Circumferential and symmetric thickenings of the bowel wall are features usually attributed to benign conditions such as inflammatory, infections, bowel oedema and ischaemia [3, 4]. However, neoplasms such as well-differentiated or small adenocarcinomas may also display symmetric and homogeneous thickening of the bowel wall and should be considered specially when the thickened bowel has a focal extension and no significant perienteric fat stranding is seen [4] (Fig. 5).
Fig. 5 Well-differentiated adenocarcinoma of the descending colon. Axial contrast-enhanced CT scan showing focal concentric and regular thickening of the descending colon (arrows) with smooth contours and homogeneous enhancement. This proved to be a well-differentiated adenocarcinoma after biopsy. Adapted from the electronic poster "Bowel wall thickening--a complex subject made simple" DOI:10.5444/esgar2011/EE-063 (3) Perienteric abnormalities (fat stranding) disproportionately greater than the degree of bowel wall thickening Inflammatory or infectious diseases of the bowel are usually centred in the bowel wall and can cause segmental or diffuse wall thickening [17]. However, in a few inflammatory enteric or perienteric conditions, the inflammatory changes are more prominent in the mesentery adjacent to the bowel rather than in the bowel wall itself. In these conditions, the bowel involvement is usually focal and mild, and the fat stranding is disproportionately greater than the degree of wall thickening. This is a helpful clue in narrowing the differential diagnosis to mainly four conditions: diverticulitis, epiploic appendagitis, omental infarction and appendicitis [17].
Diverticulitis Diverticulae are sacculations of the mucosa and submucosa through the muscularis of the bowel wall, which are more common in the descending and the sigmoid colon. Diverticulitis occurs when the neck of a diverticulum becomes occluded, resulting in microperforation and pericolonic inflammation.
CT findings of acute diverticulitis include inflamed diverticula in combination with pericolonic fat stranding, which is more severe than the mild focal thickening of the adjacent bowel wall [17]. Engorgement of the mesenteric vessels ("centipede" sign) and the presence of fluid at the base of the sigmoid mesentery ("comma sign") are two indicative signs of the inflammatory process [17, 18] (Fig. 6).
Fig. 6 Acute diverticulitis. Reformatted coronal contrast-enhanced CT scan showing sigmoid diverticuli (arrow), mild bowel wall thickening (arrowhead) and pericolonic disproportionate fat stranding. These findings are compatible with sigmoid diverticulitis Carcinoma of the colon is the most important differential diagnosis of diverticulitis when the wall thickening is more pronounced. The inflamed diverticula, homogeneous bowel wall enhancement, mesenteric signs of inflammation and lack of lymph nodes in light of the acute clinical presentation--localised pain and fever--support the diagnosis [18, 19].
Epiploic appendagitis Epiploic appendages are pedunculated adipose structures protruding from the serosa surface of the colon into the peritoneal cavity. Acute epiploic appendagitis results from the torsion or venous occlusion of the epiploic appendage and is more frequent in the sigmoid colon [20].
CT findings of epiploic appendagitis include the presence of a fat-density lesion corresponding to the inflamed appendix with surrounding inflammatory changes [20]. The engorged or thrombosed vessel may be seen as a high-attenuation focus within the fatty lesion ("central dot sign"), which constitutes a helpful finding to the diagnosis [20]. Mild reactive thickening of the colonic wall is often seen, but the paracolic inflammatory changes are disproportionately more severe [17, 20] (Fig. 7).
Fig. 7 Epiploic appendagitis of the descending colon. Axial contrast-enhanced CT scan shows the inflamed epiploic appendage anterior to the colonic wall (asterisk) with adjacent disproportionate fat stranding and minimal wall thickening of the descending colon (arrow). Adapted from the electronic poster "Bowel wall thickening--a complex subject made simple" DOI:10.5444/esgar2011/EE-063 Omental infarction Infarction of the greater omentum may occur spontaneously, especially in obese people, or be secondary to abdominal surgery [7]. It is more common on the right side of the omentum and may clinically simulate appendicitis or cholecystitis. CT findings of omental infarction include a high-attenuation fatty mass centred in the omentum. Reactive bowel wall thickening of the colon may occur when the infarcted omentum is adjacent to it, but fat stranding is disproportionately more severe compared to the degree of bowel wall thickness [7] (Fig. 8).
Fig. 8 Omental infarction. Axial contrast-enhanced CT scan of a patient who presented with acute right upper quadrant pain shows an inhomogeneous fatty mass (large arrow) in the greater omentum, indicative of omental infarction. Note the mild wall thickening (arrow) of the adjacent colonic wall, which is clearly disproportionate relative to the fat stranding. Adapted from the electronic poster "Bowel wall thickening--a complex subject made simple" DOI:10.5444/esgar2011/EE-063 Acute appendicitis Acute appendicitis occurs when the appendiceal lumen becomes occluded, resulting in inflammation, ischaemia and eventually perforation [7, 17]. CT findings of acute appendicitis include a fluid-filled dilated (>6 mm in diameter) appendix, thickness of the wall, and mild to moderate peri-appendicular fat stranding. An appendicolith is present in up to 40 % of the cases. Mild thickening of the caecal apex wall may also occur (caecal bar and the arrowhead sign) [7, 17]. When the appendicitis is complicated with perforation and abscess formation, the appendix may be difficult to see. In these cases, severe fat stranding of the right lower quadrant is common and in the absence of substantial caecal and ileal thickening suggests the diagnosis [17] (Fig. 9).
Fig. 9 Acute appendicitis. Axial (a) and coronal (b) contrast-enhanced CT scan shows the retrocaecal enlarged fluid-filled appendix (arrows) associated with adjacent fat stranding and reactive wall thickening of the ascending colon (asterisk) Segmental or diffuse bowel wall thickening When the thickened bowel has an extension of 6-40 cm or greater than 40 cm, it is considered a segmental or diffuse thickening respectively [3, 4]. Segmental or diffuse circumferential and symmetric thickening of the bowel wall is typically secondary to benign conditions and usually does not exceed 10 mm in thickness from the luminal to the serosal surface [10, 11]. As mentioned above, the exception is the small bowel lymphoma, which despite being a malignant condition may present with a segmental distribution causing circumferential symmetric thickening of the bowel wall and homogeneous low attenuation after intravenous contrast administration [3, 4, 10, 11] (Fig. 10).
Fig. 10 Small bowel lymphoma. Reformatted coronal contrast-enhanced CT scan shows concentric and regular segmental thickening of a small bowel loop (arrows) with homogeneous contrast enhancement. Adapted from the electronic poster "Bowel wall thickening--a complex subject made simple" DOI:10.5444/esgar2011/EE-063 In the setting of segmental or diffuse bowel wall thickening, one of three attenuation patterns after intravenous contrast administration may occur: a stratified attenuation pattern, white attenuation pattern or grey attenuation pattern [4, 6, 21].
Stratified pattern of attenuation In this pattern, two (double halo sign) or three (the target sign) concentric and symmetric layers of alternating densities are recognised on the thickened bowel wall after intravenous contrast administration.
This pattern indicates inflammation or ischaemia of the bowel where the inner and outer high-density layers correspond to the hyperemic mucosa and serosa, respectively, while the low-density layer presumably represents the oedematous submucosa [2-4, 6, 7, 11, 21].
Although generally indicative of benign conditions, these signs are not specific and may be present in several acute conditions. Clinical presentation and adjacent findings such as perienteric findings help in narrowing the differential diagnosis:
Bowel ischaemia Thickening of the bowel wall is the most common but least specific CT sign of bowel ischaemia [5, 22]. The extent of involvement, degree of thickness and pattern of attenuation of the ischaemic bowel vary according to three main factors: (1) pathogenesis of the ischaemia (arterial-occlusive, veno-occlusive or hypoperfusion); (2) severity of the ischaemia (transient ischaemia of the mucosa and/or submucosa versus transmural bowel wall necrosis); (3) superimposed haemorrhage or infection [5].
Although bowel wall thickening is a common finding in cases of bowel ischaemia, the ischaemic bowel wall may also appear paper thin, particularly in cases of acute arterial occlusion [5].
When the ischaemic bowel wall is thickened, it may present with one or more of the three above-mentioned attenuation patterns referred [3, 5, 23]. The stratified pattern of attenuation may be an early finding of bowel ischaemia. This results from oedema of the submucosa and hyperaemia or hyperperfusion of the mucosa and/or muscularis propria [5, 6, 21, 24]. This finding should be judged in the clinical context and associated imaging findings of bowel ischaemia, such as occlusion of the mesenteric artery or vein, bowel dilatation, engorgement of the mesenteric veins, and mesenteric oedema and ascites [3, 11, 21, 22, 25] (Fig. 11). Intestinal pneumatosis and gas in the mesenteric or portal veins are indicative of severe ischaemia and are usually associated with the thinning rather than thickening of the small bowel wall due to bowel wall necrosis [24].
Fig. 11 Acute small bowel ischaemia. Axial contrast-enhanced CT scan shows diffuse thickening of the small bowel loops with a target appearance (arrow) due to submucosal oedema. Also note the engorgement of the mesenteric root vessels and ascites, common findings in cases of acute bowel ischaemia. Adapted from the electronic poster "Bowel wall thickening--a complex subject made simple" DOI:10.5444/esgar2011/EE-063 Vasculitides are rare causes of gastrointestinal ischaemia with the highest prevalence in polyarteritis nodosa and usually present with thickening of the affected bowel wall with a stratified appearance [3, 24]. Distinguishing between ischaemia due to vasculitides and other causes of mesenteric ischaemia may be difficult based on radiologic findings alone (Fig. 12). This diagnosis, however, should be considered whenever mesenteric ischaemic changes occur in young patients; involve unusual sites such as the stomach, duodenum and rectum, and is not confined to a single vascular territory. In addition, systemic clinical manifestations (i.e. fever, weakness, malaise, myalgia and headache) point to the correct diagnosis [24].
Fig. 12 Bowel ischaemia secondary to systemic lupus erythaematosus (LES). Axial contrast-enhanced CT scan shows circumferential thickening of the small bowel loops (arrows) with a stratified appearance in a patient with LES presenting with bloody diarrhoea indicating bowel involvement by the vasculitis Idiopathic inflammatory bowel disease Bowel wall thickening with a stratified pattern may be also seen in both ulcerative colitis (UC) and Crohn's disease, indicating acute, active disease [2, 7, 26].
Crohn's disease may occur in any part of the gastrointestinal tract but predominantly affects the small bowel, particularly the ileum and right colon [2, 7]. CT signs favouring Crohn's disease include discontinuous involvement of the bowel wall ("skip areas"), prominent vasa recta ("comb sign") and signs of transmural inflammation such as fistulas and abscesses, and proliferation of the fat along the mesenteric border of the bowel [2, 3, 7] (Fig. 13).
Fig. 13 Stratified appearance in Crohn's disease. Axial contrast-enhanced CT scan of the abdomen shows concentric wall thickening of small bowel loops with a stratified appearance indicating active disease (arrows). Also note a fistula (arrowhead) connecting the bowel loops, a common finding in Crohn's disease By contrast, UC is typically left sided, involves the rectum in 95 % of cases, and shows contiguous, circumferential and proximal extension through the colon [27]. The inflammatory process in UC is superficial, predominantly affecting the mucosa [7]. Thus, wall thickening and pericolonic involvement are not as extensive in ulcerative colitis as they are in Crohn's disease [27].
Infectious enteritis or colitis and pseudomembranous colitis In most cases of infectious enteritis the small bowel wall appears normal or mildly thickened [3]. By contrast, infectious colitis typically manifests with significant wall thickening, which may demonstrate either homogeneous enhancement or a striated pattern due to intramural oedema. Stranding of the pericolic fat and ascites are also commonly seen [7, 28, 29]. Although the affected portion of the colon may suggest a specific organism, there is a considerable overlap of the appearances. Thus, laboratory studies are needed to achieve a definitive diagnosis [7].
Pseudomembranous colitis results from toxins produced by an overgrowth of the organism Clostridium difficile and usually presents as a pancolitis. The degree of bowel wall thickness in pseudomembranous colitis and cytomegalovirus colitis is usually greater than in any other inflammatory or infectious disease of the colon, while the pericolic fat stranding is often disproportionately mild [2, 9] (Fig. 14). After intravenous contrast administration, the thickened bowel wall may show low attenuation due to oedema, hyperenhancement due to hyperaemia or a striated appearance. When haustral folds are significantly thickened and protrude into the bowel lumen, they can trap the positive oral contrast material, an appearance known as the "accordion sign". This sign suggests the diagnosis, although it may also occur from other causes of colitis [26].
Fig. 14 Stratified attenuation pattern in pseudomembranous colitis. Axial contrast-enhanced CT scan shows significant wall thickening of the ascending and descending colon (arrows) due to submucosal oedema, resulting in the stratified appearance. The marked thickening of the bowel wall and the mild pericolonic fat stranding suggest pseudomembranous colitis Specific clinical entities The striated attenuation may also be seen in specific clinical situations, such as graft-versus-host disease in patients submitted to allogeneic bone marrow transplantation, acute radiation enteritis or colitis in patients submitted to radiation therapy, bowel wall oedema in patients with a history of angioedema, and oedema of the right colon in cirrhotic patients [3, 7] (Figs. 15 and and16).16). In each of these conditions the appropriate clinical history is essential for establishing the correct diagnosis.
Fig. 15 Radiation enteritis in a patient with cervical cancer. Axial contrast-enhanced CT scan shows concentric stratified wall thickening of low-lying small bowel loops (arrows). There are also some ascites. These findings in the context of radiation therapy are suggestive of radiation enteritis Fig. 16 Stratified attenuation pattern in the ascending colon of a cirrhotic patient. Reformatted coronal contrast-enhanced CT scan shows parietal regular and concentric thickening of the ascending colon (arrows) with a "target" appearance due to oedema of the submucosa. Note the irregular contours of the liver (arrowheads) consistent with hepatic cirrhosis. Adapted from the electronic poster "Bowel wall thickening--a complex subject made simple" DOI:10.5444/esgar2011/EE-063 Other causes of stratified appearance Stratification of the bowel wall may also be caused by infiltration of the submucosa by tumour or fat. The rare infiltrating scirrhous carcinomas (linitisplastica) of the stomach or rectosigmoid may present with symmetric wall thickening, regular contours and stratification of the bowel wall [4, 11]. Narrowing of the intestinal lumen, regional adenopathy and distant metastasis point to the correct diagnosis [11].
A target appearance may also be caused by deposition of fat in the submucosa, indicating past or chronic inflammation [2, 7]. It is more common in patients with idiopathic inflammatory bowel disease, especially ulcerative colitis (Fig. 17). Occasionally this sign can also be seen in patients with a history of radiation enteritis and even in patients with no history of gastrointestinal disease, where the intramural fat layer is usually much thinner than that seen in inflammatory bowel disease [3, 6, 27].
Fig. 17 Fat halo sign in Crohn's disease. Axial contrast-enhanced CT image shows concentric wall thickening of the rectum (arrow) with fatty appearance of the submucosa in a patient with a long history of Crohn's disease White pattern of attenuation The white pattern is caused by intense enhancement of the bowel wall when its density is equal to or greater than that of venous vessels in the same scan [6]. Visual assessment is usually sufficient to detect hyperenhancement of the wall when the bowel lumen is well distended [3]. This pattern can be seen mainly in two clinical entities: ischaemia and inflammatory bowel disease.
Ischaemia Hyperenhancement of the ischaemic bowel may occur because of the hyperaemia (i.e. mesenteric venous occlusion with outflow obstruction) or hyperperfusion (i.e. reperfusion after occlusive or nonocclusive ischaemia) of the bowel wall and is a good prognostic factor, indicating viability of the bowel wall [5, 22, 25]. As referred to above, associated imaging findings of bowel ischamia include occlusion of the mesenteric vessels, bowel dilatation, mesenteric oedema and ascites [3, 11, 22, 23, 26].
The white pattern may also occur in patients with acute hypovolaemia or shock known as "shock bowel" [3] (Fig. 18). In this setting increased vascular permeability of the bowel wall leads to interstitial leakage of the contrast material resulting in higher attenuation [5, 6, 24, 30, 31].
Fig. 18 Shock bowel in a patient with significant haemorrhage due to bleeding oesophageal varices. Axial contrast-enhanced CT scan shows thickened hyperattenuating small bowel loops (arrow) due to the increased vascular permeability in the context of severe hypovolaemia. Also note engorgement of the mesenteric vessels and small volume ascites Hyperattenuation of the bowel wall may also occur because of intramural haemorrhage in patients with bowel ischaemia, bleeding diathesis or undergoing anticoagulation therapy [5, 23]. Taking this into account, acquisition of both unenhanced and enhanced CT studies is essential in the distinction between hyperenhancement of the bowel wall and spontaneous hyperattenuation due to acute intramural haemorrhage [3, 4, 32] (Fig. 19).
Fig. 19 White attenuation pattern due to spontaneous intramural bowel wall haemorrhage in a patient with polyarteritis nodosa. Axial unenhanced (a) and contrast-enhanced (b) CT scans of the abdomen show concentric wall thickening of the third duodenal portion that showed spontaneous hyperenhancement of the bowel wall due to spontaneous haemorrhage. Adapted from the electronic poster "Bowel wall thickening--a complex subject made simple" DOI:10.5444/esgar2011/EE-063 Inflammatory conditions Homogeneous hyperenhancement of the thickened bowel wall may also occur in the setting of infectious and idiopathic inflammatory bowel disease. In the latter case, hyperenhancement of the bowel wall indicates active disease [2, 3, 33] (Fig. 20).
Fig. 20 White attenuation pattern in Crohn's disease. Axial (a) and coronal (b) contrast-enhanced CT scans show homogeneous hyperenhancement (arrows) of a thickened and stenotic ileal loop indicating active disease. Note the proximal dilatation of the small bowel loops (asterisk) due to the obstruction Grey pattern of attenuation The grey pattern of attenuation indicates mild to diminished enhancement of the bowel wall and is considered when the attenuation of the bowel wall is similar to that of the muscle on contrast-enhanced scans [6]. In general this pattern corresponds to the least specific of the attenuation categories and so other imaging findings and clinical presentation are essential in establishing the correct diagnosis [6].
Acute onset In the appropriate clinical setting decreased enhancement of the bowel wall may represent a compromise of the blood supply to the bowel wall and is pathognomonic of intestinal ischaemia [3, 10, 24]. The hypoattenuating bowel wall usually has a homogeneous appearance and is caused by bowel wall oedema [5] (Fig. 21). This pattern is particularly common in cases of mesenteric venous occlusion and bowel obstruction, where the bowel oedema is more pronounced due to venous congestion [23]. It is also frequent in ischaemic colitis, a common cause of abdominal pain in the elderly [7]. Ischaemic colitis results when blood flow to the colon is compromised, usually as a result of hypoperfusion. Although left-sided involvement is more common, diffuse or segmental involvement of the colon may occur depending on the cause and which vessels are involved [7] (Fig. 22).
Fig. 21 Grey attenuation pattern in small bowel ischaemia. Axial contrast-enhanced CT scans show distended fluid-filled small bowel loops (asterisks in a and b) with hypoenhancing thick walls (thin arrows in a and b) indicating ischaemia in a patient with partial occlusion of the superior mesenteric artery (large arrow in a). Adapted from the electronic poster "Bowel wall thickening--a complex subject made simple" DOI:10.5444/esgar2011/EE-063 Fig. 22 Ischaemic colitis. Axial contrast-enhanced CT scans through the descending colon (a) and rectum (b) show the thickened hypoattenuating bowel wall due to ischaemia. The diagnosis was confirmed with colonoscopy and biopsy Delayed onset In patients with chronic Crohn's disease or chronic radiation enteritis, involved bowel loops may show diminished enhancement due to the development of transmural fibrosis [3, 4, 6]. Once transmural fibrosis has developed in Crohn's disease, mural stratification is no longer seen. In this context, homogeneous low attenuation of the bowel indicates quiescence of the disease.
Chronic radiation enteritis or colitis may develop 6-24 months after completion of radiation therapy. Distribution is related to treatment fields and most frequently involves the rectum and sigmoid because of radiation for pelvic disease (most commonly prostatic or cervical cancer) [9]. CT findings of chronic radiation enteritis include hypoenhancing wall thickening, increased pelvic fat and thickening of the perienteric fibrous tissue [32]. Strictures and fistulas may also occur [33].
Conclusion Bowel wall thickening may be focal and segmental or diffuse. In cases of focal thickening, the degree and symmetry of thickening and perienteric abnormalities help narrow the differential diagnosis: while heterogeneous and asymmetric focal thickening is usually associated with malignancies, symmetric regular and homogeneous thickening may be caused by benign conditions but also well-differentiated tumours. Disproportionate fat stranding compared to the degree of wall thickening suggests inflammatory conditions. Segmental or diffuse bowel thickenings are usually caused by benign conditions, with the exception of lymphoma. Common causes include ischaemia, inflammatory and infectious conditions. The pattern of attenuation helps narrow the differential diagnosis of segmental or diffuse wall thickening but still there is a significant overlap on CT imaging findings of different non-neoplastic bowel conditions.
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A colostomy is an operation that creates an opening for the colon, or large intestine, through the abdomen. A colostomy may be temporary or permanent. It is usually done after bowel surgery or injury. Most permanent colostomies are "end colostomies," while many temporary colostomies bring the side of the colon up to an opening in the abdomen.
During an end colostomy, the end of the colon is brought through the abdominal wall, where it may be turned under, like a cuff. The edges of the colon are then stitched to the skin of the abdominal wall to form an opening called a stoma. Stool drains from the stoma into a bag or pouch attached to the abdomen. In a temporary "loop colostomy," a hole is cut in the side of the colon and stitched to a corresponding hole in the abdominal wall. This can be more easily reversed later by simply detaching the colon from the abdominal wall and closing the holes to reestablish the flow of stool through the colon.
A colostomy won't change the way your digestive system works. Normally, after you chew and swallow your food, it goes through your esophagus, or swallowing tube, into your stomach.
From there, it travels to your small intestine and then to your large intestine, or colon. Hours or days later, the indigestible residue leaves the storage area of your rectum via your anus, as stool. Stool typically stays loose and liquid during its passage through the upper colon. There, water is absorbed from it, so the stool gets firmer as it nears the rectum.
The ascending colon goes up the right side of your body. The stool here is liquid and somewhat acidic, and it contains digestive enzymes. The transverse colon goes across your upper abdomen, and the descending and sigmoid colon go down the left side of your body to your rectum. In the left colon, the stool becomes progressively less liquid, less acidic, and contains fewer enzymes.
Where your colon is interrupted determines how irritating to the skin your stool output will be. The more liquid the stool, the more important it will be to protect your abdominal skin after a colostomy.
Getting a colostomy marks a big change in your life, but the surgery itself is uncomplicated. It will be performed under general anesthesia, so you will be unconscious and feel no pain. A colostomy may be done as open surgery, or laparoscopically, via several tiny cuts.
As with any surgery, the main risks for anesthesia are breathing problems and poor reactions to medications. A colostomy carries other surgical risks:
Bleeding Damage to nearby organs Infection After surgery, risks include:
Narrowing of the colostomy opening Scar tissue that causes intestinal blockage Skin irritation Wound opening Developing a hernia at the incision So these difficulties for the outcome of the foreign body left in the body of the patient during her operation in Sahara Hospital. All these show the negligece and carelessness on the part of the Sahara Hospital. Res ipsa loquitur Maxim is perfectly applicable in this case.
The opposite party no 1 is the hospital where the aggrieved person was admitted and operated. What are the basic needs of such a hospital dealing with such cases.
Healthcare set-ups are constantly evolving and providing advanced services and medical care. You may be spoilt for choice, but to give you a general idea, we've listed out five essential facilities that you should look out for when choosing a maternity hospital or nursing home.
Now we have to see about the post-operative care. Every nursing home or hospital should have proper and efficient post-operative care unit so that the patient after operation should be kept under active supervision of the doctorS and paramedical staffS. In this case we not find any proper and efficient post-operative medical care. Regarding immediate post-operative care we have to produce the following article.
Immediate postoperative care:
Postoperative patients must be monitored and assessed closely for any deterioration in condition and the relevant postoperative care plan or pathway must be implemented.
The NCEPOD (2011) report found that patients whose condition was deteriorating were not always identified and referred for a higher level of care. Patients should be made as comfortable as possible before postoperative checks are performed.
Postoperative patients are at risk of clinical deterioration, and it is vital that this is minimised. Knowledge and understanding of the key areas of risk and local policies will help reduce potential problems (National Patient Safety Agency, 2007; National Institute for Health and Clinical Excellence, 2007).
Track and trigger or early warning systems are widely used in the UK to identify deteriorating patients. These have been adapted by trusts for adults and children and are based on the patient's pulse and respiratory rate, systolic blood pressure, temperature and level of consciousness. Additional monitoring may include pain assessment, capillary refill time, percentage of oxygen administered, oxygen saturation, central venous pressure, infusion rates and hourly urine output.
The National Early Warning Score (NEWS) was developed by a working party to provide a national standard for assessing, monitoring and tracking acutely and critically ill patients (not for use with children under 16 years or in pregnancy); the intention was that trusts would use it to replace their locally adapted early warning systems (Royal College of Physicians, 2012). Like other early warning systems, NEWS has six physiological parameters:
Respiratory rate;
Oxygen saturation;
Temperature;
Systolic blood pressure;
Pulse rate;
Level of consciousness (this will be impaired in patients who have had recent sedation or are receiving opioid analgesia, which should be taken into consideration in assessment).
The system also includes a weighting score of two, which is added if the patient is receiving supplemental oxygen via a mask or nasal cannulas.
When assessing the postoperative patient using NEWS, it is vital that the patient is observed for signs of haemorrhage, shock, sepsis and the effects of analgesia and anaesthetic. Patients receiving intravenous opiates are at risk of their vital signs and consciousness levels being compromised if the rate of the infusion is too high. It is therefore imperative that the patient's pain control is managed well, initially by the anaesthetist and then the ward staff and pain team or anaesthetist, to ensure that the patient has adequate analgesia but is alert enough to be able to communicate and cooperate with clinical staff in the postoperative period.
Many trusts have yet to implement NEWS, although it is beginning to be taught in pre-registration nursing programmes. Student nurses frequently perform postoperative observations under the supervision of a nurse; it is reassuring that they receive some insight and education as recommended by NCEPOD (2011).
Vital signs;
Vital signs should be performed in accordance with local policies or guidelines and compared with the baseline observations taken before surgery, during surgery and in the recovery area.
Nurses should also be aware of the parameters for these observations and what is normal for the patient under observation. When assessing patients' recovery from anaesthesia and surgery, these observations should not be considered in isolation; the nurse should look at and feel the patient. This also applies to children and should include observation of other signs and symptoms, for example abdominal tenderness or poor urine output, which could indicate deterioration (Royal College of Nursing, 2011). The RCN (2011) provides guidance on vital signs performed post-operatively on children. Many trusts now insist that vital signs are performed manually to provide more accurate recording and assessment.
All vital signs and assessments should be recorded clearly in accordance with guidelines for record keeping (Nursing and Midwifery Council, 2009). Handheld personal digital assistants (PDAs) are used at some trusts to store track and trigger data and calculate early warning scores, which can be accessed by the clinical and outreach teams.
When a patient's condition is identified as deteriorating, this information can be passed verbally to appropriate health professionals using the Situation, Background, Assessment and Recommendation (SBAR) tool advocated by the NHS Institute for Innovation and Improvement (2008).
Airway and respirations Respiratory rate and function is often the first vital sign to be affected if there is a change in cardiac or neurological state. It is therefore imperative that this observation is performed accurately; however, studies show it is often omitted or poorly assessed (NPSA, 2007; NCEPOD, 2005).
Nurses should observe and record the following:
Airway;
Respiratory rate (regular and effortless), rhythm and depth (chest movements symmetrical);
Respiratory depression: indicated by hypoventilation or bradypnoea, and whether opiate-induced or due to anaesthetic gases.
Oxygen therapy Oxygen is administered to enable the anaesthetic gases to be transported out of the body, and is prescribed when patients have an epidural, patient-controlled analgesia or morphine infusion. Nurses should ensure and record the following:
Oxygen therapy is prescribed;
Oxygen is administered at correct rate;
Continuous oxygen therapy is humidified to prevent mucous membranes from drying out;
The skin above the ears is protected from elastic on the mask.
Pulse oximetry Oxygen saturation should be above 95% on air, unless the patient has lung disease, and maintained above 95% if oxygen therapy is prescribed to prevent hypoxia or hypoxaemia. An abnormal recording may be due to shivering, peripheral vasoconstriction or dried blood on the finger.
Nurses should ensure that:
The finger probe is clean;
The position of the probe is changed regularly to prevent fingers becoming sore.
Heart rate, blood pressure and capillary refill time The following should be checked and recorded:
Rate, rhythm and volume of pulse;
Blood pressure;
Capillary refill time to assess circulatory status, along with the colour and temperature of limbs, also identifying reduced peripheral perfusion.
Particular attention should be paid to the systolic blood pressure as a lowered systolic reading and tachycardia may indicate haemorrhage and/or shock, although initially the blood pressure may not drop and will remain within normal limits as the body compensates. Tachycardia may also indicate that the patient is in pain, has a fluid overload or is anxious. Hypertension can be due to the anaesthetic or inadequate pain control.
Body temperature Children, older adults and patients who have been in theatre for a long period are at risk of hypothermia. Shivering can be due to anaesthesia or a high temperature indicative of an infection, while a drop in temperature might indicate a bacterial infection or sepsis.
Patients' temperature should be monitored closely and action taken to return it to within normal parameters.
Use a Bair Hugger (forced-air blanket) and blankets to warm the patient if their temperature is too low;
Choose an appropriate method to cool the patient if their temperature is too high (antipyretics/fanning/ tepid sponging).
Level of consciousness Postoperative patients should respond to verbal stimulation, be able to answer questions and be aware of their surroundings before being transferred to the ward and throughout the postoperative period.
A change in the level of consciousness can be a sign that the patient is in shock. The AVPU scale (Box 2) is appropriate for assessing consciousness in adults, children and young people unless they have had neurosurgery (RCN, 2011).
Fluid balance The NCEPOD (2011) found, in 30% of patient data reviewed, there was insufficient recording of postoperative fluid balance. Nurses should observe/undertake and record on the fluid balance chart the following:
IV fluids (colloids and crystalloids used to replace fluid loss postoperatively) and infusions;
Oral intake;
Urine output: catheter urine measurements should not be less than 0.5ml/kg/hour. Oliguria can be a sign of hypovolaemia and should be reported to medical staff immediately. Check that the catheter is not kinked or that the patient is not lying on the tubing if urine output is reduced;
Colour of stoma (where appropriate) and whether there is any bleeding;
Nausea and vomiting: if necessary, administration of antiemetics should be checked and vomit bowls and tissues should be within easy reach of the patient;
Oral care;
Nasogastric tube drainage (aspirate if patient feels nauseous unless otherwise indicated);
Colour and amount of wound drainage: large amounts of fresh blood could be an indication of haemorrhage; if there is no wound drainage, it is advisable to check that the drain has not fallen out.
Intravenous infusions The RCN (2010) and Health Protection Scotland (2012) recommend that peripheral venous catheters (PVC) are checked daily as a minimum, and consideration given to removing any PVC that has been in situ longer than 72 hours (Health Protection Scotland, 2012) or 72-96 hours (Department of Health, 2011).
A phlebitis scale can be used to help assess the PVC site; the Visual Infusion Phlebitis Scale (Jackson, 1998) is frequently used and recommended by the RCN (2010). These national guidelines should be used as resources in caring for PVCs. The following should be checked and recorded:
The PVC site when changing IV fluids, before administering IV medication;
Signs of phlebitis (redness, heat and swelling).
Conclusion The postoperative healthcare team is under constant pressure to discharge patients quickly. This can lead to vital signs being missed and result in a delay in recovery.
Patients can be discharged quickly only when they do not experience any post-operative complications, many of which can be avoided or identified with correct and thorough monitoring of signs and symptoms.
All health professionals must continually update their theoretical knowledge and clinical skills; those working in post-operative care can do this by relying less on electronic equipment and developing their ability to combine the use of assessment tools with good observational skills; feeling, listening for abnormal sounds and closely observing their patients.
There are guidelines issued by World Health Organisation for Post Operative Care - these are Postoperative care Post operative note and orders The patient should be discharged to the ward with comprehensive orders for the following:
• Vital signs • Pain control • Rate and type of intravenous fluid • Urine and gastrointestinal fluid output • Other medications • Laboratory investigations The patient's progress should be monitored and should include at least:
• A comment on medical and nursing observations • A specific comment on the wound or operation site • Any complications • Any changes made in treatment Aftercare: Prevention of complications • Encourage early mobilization:
o Deep breathing and coughing o Active daily exercise o Joint range of motion o Muscular strengthening o Make walking aids such as canes, crutches and walkers available and provide instructions for their use • Ensure adequate nutrition • Prevent skin breakdown and pressure sores:
o Turn the patient frequently o Keep urine and faeces off skin • Provide adequate pain control Discharge note On discharging the patient from the ward, record in the notes:
• Diagnosis on admission and discharge • Summary of course in hospital • Instructions about further management, including drugs prescribed.
Ensure that a copy of this information is given to the patient, together with details of any follow-up appointment .
(WHO/EHT/CPR: WHO Surgical Care at the District Hospital 2003 Postoperative Management) If the patient is restless, something is wrong.
Look out for the following in recovery:
• Airway obstruction • Hypoxia • Haemorrhage: internal or external • Hypotension and/or hypertension • Postoperative pain • Shivering, hypothermia • Vomiting, aspiration • Falling on the floor • Residual narcosis The recovering patient is fit for the ward when:
• Awake, opens eyes • Extubated • Blood pressure and pulse are satisfactory • Can lift head on command • Not hypoxic • Breathing quietly and comfortably • Appropriate analgesia has been prescribed and is safely established (WHO/EHT/CPR: WHO Surgical Care at the District Hospital 2003 ) Post operative pain relief • Pain is often the patient's presenting symptom. It can provide useful clinical information and it is your responsibility to use this information to help the patient and alleviate suffering.
• Manage pain wherever you see patients (emergency, operating room and on the ward) and anticipate their needs for pain management after surgery and discharge.
• Do not unnecessarily delay the treatment of pain; for example, do not transport a patient without analgesia simply so that the next practitioner can appreciate how much pain the person is experiencing.
In this case it was the duty of the opposite party to check and examined the patient after operation that is called post-operative care. CT scan or ultrasound should have been done in order to assure themselves that no carelessness or negligence has been performed by themselves but they did not do so. Usually it happens that the said Dr after performing operation used to left the operation theatre directing the resident doctors to remove the cotton gauze et cetera from the body of the person operated. And here the negligence came to play its role because the residentdoctors or para medical staffs are not serious. Such types of cases are increasing during operation and some equipment or cotton gauze has been left inside the body of the patient.
This is a case where the maxim res ipsa loquitur is applicable in full strength and as per the various judgment of the Hon'ble courts it is clear that it comes under medical negligent without any exception. So in thiscase ,the complainant has succeeded in proving his case. No doubt the complainant's wifewas admitted in opposite party no-1 where she was operated and due to carelessness of opposite parties, sponge / cotton gauze has been left inside the body which ultimately resulted in the death of the complainant's wife. In this case the opposite party - 3 along with opposite party - 1 and opposite party - 2 are responsible for the loss suffered by the complainant because of their negligence and carelessness. As far as opposite party no.4 is concerned, he is only liable to indemnify opposite parties to the extent as insured by them with insurance company.
After considering all the facts and circumstances of the case and after going through the various case law is as discussed above, we have the view that the opposite party no 1 to 3 are liable jointly as well as severally to honour the judgment of this commission. This negligence is very serious but we will see the relief claimed by the complainant in the present case. In this case, the complainant has demanded about Rs.80 lakhs as compensation. No doubt He has suffered a lot and her wife underwent two operations, and despite of it she could not be saved. Keeping in view all the circumstances and sufferings, we are of the view that compensation of Rs.80 lakhs will be genuine in this case. The opposite parties no. 1 to 3 are liable for the medical negligence while the opposite parties no.4 will indemnify respective insured persons to the extent for which they have been insured. They directed as follows-
The Opposite Parties no.1 to 3 are jointly and severally liable to pay R.80 lakhs as compensation towards loss of life of the wife of the complainant, loss of salary, mental agony, harassment and depression, medical expenses, cost the suit with interest at a rate of 10% from 24.09.2013 within 45 days from the date of judgment of this complaint case otherwise the rate of interest shall be 15% per annum from 24.09.2013 till the date of actual payment. This order shall be complied with within 45 days from the date of judgment otherwise the rate of interest will be 15% per annum. The opposite parties may be indemnified to the extent they were insured by the opposite parties no.4 in separate proceeding.
ORDER The Complaint Case is allowed with cost. The opposite parties no.1 to 3 are jointly and severally liable to pay R.80 lakhs as compensation towards loss of life of the wife of the complainant, loss of salary, mental agony, harassment and depression, medical expenses, cost of the suit with interest at a rate of 10% from 24.09.2013 payable within 45 days from the date of judgment of this complaint case otherwise the rate of interest shall be 15% per annum payable from 24.09.2013 till the date of actual payment. The opposite parties may be indemnified to the extent they were insured by the opposite parties no. 4 in separate proceeding.
If the order is not complied with in 45 days, the complainant will be free to move an application for execution at the cost of the opposite parties no. 1 and 3.
The stenographer is requested to upload this order on the Website of this Commission today itself.
Certified copy of this judgment be provided to the parties as per rules.
(Vikas Saxena ) (Rajendra Singh) Member Presiding Member Judgment dated/typed signed by us and pronounced in the open court. Consign to record. (Vikas Saxena ) (Rajendra Singh) Member Presiding Member Dated March 10, 2023 JafRi, PA I Court 2 [HON'BLE MR. Rajendra Singh] PRESIDING MEMBER [HON'BLE MR. Vikas Saxena] JUDICIAL MEMBER