State Consumer Disputes Redressal Commission
Smt Deepashree Chincholi And Another ... vs Mediciti Hospital And 3 Others ... on 3 October, 2008
THE A THE A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION: HYDERABAD C.D.NO.31 OF 2004 Between: 1. Smt Deepashree Chincholi W/o late Dr.Rajeev Chincholi Age 28 years, Housewife 2. Master Nikhil Chincholi S/o late Rajeev Chincholi Age 3 years, Minor rep. by mother and guardian complainant no.1 R/o H.No.4-6-384, Esamia Bazar, Hyderabad Complainants A N D 1. Mediciti Hospital rep. by its Managing Director/Chief Executive Officer Sri B.Narayanaswamy Age about 54 years, Secretariat Road 2. Dr.Sriramachandra Damaraju Aged about 40 years, Neurologist 3. Dr.Laxmareddy aged about 38 years Anesthetist 4. Dr.Satyanarayana Aged about 50 years Physician No.1 to 4 C/o Mediciti Hospital, Secretariat Road Hyderabad Opposite parties Counsel for the Complainants Smt I.M.Vani Counsel for the opposite parties Mr.A.Sudershan Reddy QUORUM: THE HONBLE SRI JUSTICE D.APPA RAO, PRESIDENT SMT M.SHREESHA, LADY MEMBER
& SRI G.BHOOPATHI REDDY, MEMBER FRIDAY THE THIRD DAY OF OCTOBER TWO THOUSAND EIGHT Oral Order ( As per the Smt M.Shreesha, Member) *** The brief facts as set out in the complaint are that the complainants husband was working as a Dental Surgeon in a hospital at Gulbarga and sustained head injuries while riding on a motor cycle on 24.3.2004 at 11 P.M. and was admitted in Basaveswara Hospital immediately. On the advice of the doctors in that hospital he was shifted to opposite party no.1 hospital at 4 p.m. on 25.3.2004. On that night and the next day he was under the care of opposite party no.2 doctor who is a neuro surgeon. The doctor assured that there was no danger to the life of the patient and that he would improve. At 7.30 p.m. the patient was shifted to EMD to SICU and Neurosurgeon visited the patient only once in 24 hours. The conservative treatment was continued till 28.3.2004 but there was no improvement and o the contrary the condition deteriorated. On 28.3.2004 in the afternoon his condition became serious and opposite party no.2 did not turn up till then and the complainant was informed that opposite party no.2 left for Bidar. The complainant submits that they did not entrust the treatment of patient to anybody and when the condition grew from bad to worse on the evening of 28.3.2004 the complainant and her mother requested opposite party no.1 and opposite party no.4 to save the patient. Opposite party no.3 did not treat the patient in time from 6 p.m. on 27.3.2004 till 11.35 p.m. on 28.3.2004 till the last breath of the patient. The patient died at 11.35 p.m. on 28.3.2004 and the complainant submits that the opposite parties have exhibited negligence in rendering the following services.
a) No intubation and ventilator connection was done immediately after admission, even though the Glasgow coma scale was less than VIII. Had it been done, it would have prevented aspiration of throat secretions into the lungs and would have protected the airway and also would have reduced intra cranial pressure.
b) The doctors on duty did not give antibiotics to the patient from the date of admission.
c) Even though the patient developed high fever; Physician ( Internal medicine spcecialist0 was not consulted.
d) Even till the moment of death, the patient was not given milk feeding or other liquids through nasogastrict tube (Ryles Tube ( Enteral feeding)
e) ECG, 2D Echo, and Ultra Sound of abdomen and LFT were not done and Cardiologist consultation and physician consultation was not taken
f) Elastic Stockings (TED Stockings) to the lower limbs of the patient were not put for prevention of Pulmonary embolism
g) Even till 10.00 p.m. on 28.3.2004 no physician was called to help the patient even though the patient was running high temperature of 102 degrees and no Cardiologist was called even though the heart rate was 180 per minute.
h) As already submitted Dr.Sriramachandra Damaraju, Neurosurgeon who was in charge of the patient, left for Bidar without entrusting the patient to a competent physician or surgeon. In spite of repeated requests of the complainant no.1 her mother and relatives ( some of whom are doctors) to the Hospital Authorities, no physician or neurosurgeon was called to rescue the patient from the impending danger. Opposite party no.4 Dr.Satyuanaryana who was o duty was enjoying TV in his room . Though the complainant and her relatives implored him to save the patient, never cared to stir out of the room and come to the patient and save him.
HE continued to see the TV and talk on phone.
i) Opposite party no.3 did not treat the patient from 6 p.m. on 27.3.2004 to 11 p.m. on 28.3.2004 in spite of repeated requests and opposite party no.3 represented that if it is necessary his anesthetic technician boy might be contacted. The complainant submitted that the said Mahesh is only 12th class passed and he is only to assist the anesthetist and he is not qualified to do intubation and ventilation connection. In spite of it he conducted intubation and failed to take X-ray of the chest and in spite of increase in the heart rate the cardiologist was not called to examine the patient. Only few minutes before the death the cardiologist came to resuscitate the patient.
The complainant submits that the opposite parties did not register the case as medico legal one and insisted that the complainant take away the dead body at 1.35 p.m. and though the police were informed no body turned up and the complainant shifted the dead body at 5 a.m. to Gulbarga. The case sheet and death summary was not supplied and the complainant got issued a legal notice on 28.4.2004 to furnish those documents without delay and received a reply with the death summary and a photo copy of the case sheet. The complainant submits that no antibiotics were started, no intubation, no ventilator connection was given, elastic stockings not applied, no Cardiology consultation was given for tachycardia, for dysponea there was no pulmonology consultation, anesthetist was absent, Neurosurgeon went to Bider, Ryles tube feeding was not started and there was gross negligence on behalf of the opposite party in not taking ECG, LFT, clotting test, CVP monitoring, Craniotomy worsen the oedema.
The patient finally died of Pulmonary Thromboembolism. The complainant submits that the case sheet was manipulated and the entries in the case sheet were brought into existence to cover up their negligence. The complainant further submits that her husband i.e., the patient was MDS from Gulbarga drawing a salary of Rs.15,000/- and was the only bread winner of the family. He was only 32 years old and there is a young child who is 3 and hence she seeks compensation of Rs.one crore towards mental agony and loss of life and RS.10,000/- towards costs.
Opposite party no.2 filed counter which was adopted by opposite parties 1, 3 and 4. Opposite party no.2 submitted that Dr.Kamal Kumar who was working in Medici Hospital, as a clinical associate in the ICCU happened to be the maternal uncle of complainant no.1, informed opposite party no.2 on 24.3.2004 on telephone that Dr.Raji Chincholi was grievously injured in Gulbarga that day and that the patient was being immediately transferred to opposite party no.1, since there were no facilities available in Gulbarga to handle a case of such complexity. Opposite partyno.2 waited in anticipation of grievously ill patient coming for admission that day and cancelled his appointments but however there was no admission on that day. The next day in the evening oppose party no.2 got a phone call from the emergency department by Dr.Rajeshwar Shastri that one Dr.Rajiv Chincholi had come from Gulbarga for admission and was admitted on 25.3.2004 at 4.23 p.m. as the hospital records show. Opposite party no.2 further submitted that the urgency displayed by the patients relatives on 24.3.2004, they had admitted the patient in a hospital where they knew that such facilities for treatment did not exist. More so, the most important part in the treatment of head injury is the initial 24 hours if appropriate care is not given during this period, severe secondary damage may set in. Unfortunately in the present case of Dr.Rajiv Chincholi the initial 24 hours of treatment were carried out in a centre where the necessary facilities were not available and serious secondary complications had already started to set in and there were absolutely no details available as to what treatment was given. There was a letter, without a letterhead, addressed to the neurosurgeon Medicity Hospital Hyderabad. All it mentioned was that this is a case of RTA admitted for head injury under observation. Refererd for higher centre for further management. The letter was signed for Dr.M.G.Nisty. There were no details as to what was the blood pressure status, the oxygen saturation status, electrolyte status, neurological status whether any tests were carried out. Opposite parties dont know if Mannitol, which is very critical in the treatment of head injuries was ever given in the initial 24 hours. Another important factor which was not mentioned was regarding the fluid status of the patient. It is absolutely imperative that during the treatment of any patient with injuries, severe dehydration should be avoided. This refers to the amount of water in the body. If a person is dehydrated, there is less water in the blood stream. This increases the viscosity of blood and increases the chance of clotting of blood inside the blood vessels. If clotting of blood occurs inside the blood vessels, this blocks the flow of blood and can be fatal. Such a condition probably occurred to Dr.Rajiv Chincholi on 28.3.2004.
Opposite party no.2 submitted that the patient was admitted in Mediciti Hospital on 25.3.2004 at 4.23 p.m. He was initially seen by Dr.Rajeshwar Shastri, the Casualty Medical Officer (CMO) who informed opposite party no.2 on the phone that such a patient had come to the hospital. Then opposite party no.2 rushed there and made the following observations.
a) This 32 years old male was known to consume alcohol regularly.
This information was in fact provided by the patients relatives.
b) According to the relatives he consumed alcohol and went on a motorcycle and had an accident with a bicycle and sustained a severe head injury.
c) The said patient fell on the left side of the head and had an injury in the region of the ear. He lost consciousness after the fall. This was due to the fact that the impact of the fall was sufficient to transmit the force to the brain causing it to stop functioning.
d) IT was also noticed that the said patient had clear fluid discharging from the left ear. It was diagnosed as CSF (cerebrospinal fluid) otorrhoea. This injury was severe enough for the force to crack the skull tear the dura mater and damage the ear canal for the CSF fluid to come out. Most of the time the leak stops by itself.
Antibiotics are usually not used to prevent infections of the brain in patients with skull base fractures causing CSF otorreha. Hence antibiotics were not started it he treatment of Dr.Rajiv Chincholi.
e) The patient was also very restless at the time fo admission to the hospital. He was given Inj. Halperidol which si a strong sedative before the CT scan was done so that he could lie still in the machine during the period for the examination.
Hence when opposite party no.2 examined him, his blood pressure was 150/90 mm Hg. His pulse was 120/min. both pupils were 2 mm and reacting to light equally. He was moving limbs on both sides. All these indicated that the patient had a severe head injury.
He was not opening eyes to call not making sounds and was localizing pain. According to the Glasgow coma score, he had a score of 7/15. Since the initial assessment was done under the influence of haloperidol, it was possible that the patients neurological status may be been pharmacologically depressed.
f) The arterial blood gas study showed the patient had hypoxia. He also had hypercapnia. This shows that the patient had not received adequate oxygen during his initial stay in Gulbarga nor during his transfer to Mediciti.
g) The CT scan showed a thin right fronto-temporal acute subdural haemotoma; this is a blood clot which collects between the dura mater which is a covering of the brain, and the brain itself. There was a small fronto-temporal contusion; this is an area of damage to frontal and temporal lobes of the brain with areas of bleeding at the capillary level. There was associated subarachnoid blood; this reers to blood between the brain and the arachnoid membrane, which is another layer between the dura mater and the brain.
There was a midline shift to the left by about 2-3 mm; this refers to movement of the brain to the opposite side by 2-3 mm. Most of the time, midline shift of 5 mm is considered critical and surgery is warranted to remove the clot. Since the midline shift was only 2-3 mm surgery was not the preferred modality of treatment. There was a fracture of the left temporal bone, the left petrous bone going across the clivus to the opposite side. This refers the fact that the injury was so strong that the fracture line traveled across the skull to the opposite side. It is well known that the base of the skull is one of the toughest parts of the skull and fracture lie which travels across the midline is indicative of the severity of the injury.
h) Since the acute subdural haematoma was giving rise to a midline shift by about 2-3 mm only, it was decided not to operate on the patient, but to treat him with medications only. Accordingly the patient was started on INj. Mannitol 100 m. QID.
Mannitol is a drug well known in the treatment of head injury. Inj. Eposlin 400 mg daily dissolved in Normal Saline. This medication is used to prevent seizures. Inj. Pantodac 40 mg daily. This is iven to prevent bleeding from the stomach, which is well known to occur in head injuries. Inj. Diclofenac 50 mg TID. This is given for pain relief. Intravenous fuids were administered since the patient was not taking any fluid from the mouth. HE was given 5 bottles of intravenous fluids. This translates to about 2500 ml per day.
Opposite party no.2 denied that in spite of knowing fully well that the patient was in critical condition, he visited the patient only once in 24 hours and that there was no improvement in the condition of the patient.
With regard to ventilation it was not planned since the role of ventilation in head injury is primarily to prevent secondary injury to the brain which may occur in the first 24 hours. Also it helps to maintain good oxygenation of the blood. Since the patient was breathing normally and the blood oxygen saturation was being maintained well, he was not kept on a ventilator. It is further submitted that Heparin is usually given to patients who are unconscious to prevent DVT. But this cannot be given in patients with bleeding inside the brain. On 25.3.2004 the patient was admitted in the surgical intensive care unit and there is always a doctor on duty who is available round the clock. The duty doctors constantly monitor the patient round-the-clock. The patient was seen by the duty doctor who recorded that evening at 7 p.m. that all the vital parameters were stable and he informed opposite party no2. On telephone and continued the same treatment. On the morning of 26.3.2004 the patient was found to have low grade temperature and opposite party no.2 advised him to start the patient on tepid sponging. Low grade fever is a common condition and usually includes administering paracetamol injection and sponging with a wet cloth so that the fever can be reduced by physical methods. Hence antibiotics were not given. It is completely false to suggest that the patient should be given milk feeding or other liquids through nasogastric tube. In fact, after a severe head injury, patients have delayed emptying of the stomach into the intestine, a condition called gastric stasis. No enteral feeding is given after a severe head injury for at least 4-5 days. If enteral feedings is done, the fluids are highly likely to reflux back casing a dangerous condition called aspiration pneumonia. This is a condition where there is severe infection in the lungs and can actually cause death of the patient. With regard to ECG, 2D Echo, and ultra sound of abdomen and LFT not being done and Cardiologist consultation and physician consultation not taken, opposite party no.2 submits that since the patient was admitted with a head injury, these investigations are done only in patients who are admitted with a cardiac problem or a general medial problem such as diabetes or hypertension. In fact Dr.Kamal Kumar who is a relative of the patient is well versed in the usefulness of these investigations.
Opposite party no.2 reviewed the patient later that day and found that there was no change in the neurological status and advised to continue the same treatment.
Opposite party no.2 further submitted with regard to DVT that stagnation of blood in the legs leads to clotting of blood in the legs. This is called deep vein thrombosis. DVT in the legs is an important cause of pulmonary thrombo-embolism which is a condition where the clot from the leg moves upto the heart.
This leads to blockage of blood in the main blood vessels leading away from the heart, specifically the pulmonary artery and that this can lead to cardiac arrest and death. It is submitted that since the patient was very restless, opposite partyno.2 felt that the cause of restlessness was possibly due to alcohol withdrawal. Sudden stoppage of alcohol in a chronic alcoholic causes a condition called delirium tremens where there is very violent agitation by the concerned patient.
Opposite party no.2 also felt that the head injury could be causing the same agitation. To rule out the chance that there could be an increase in the size of the haematoma, opposite party no.2 advised a repeat CT scan to be done on 27.3.2004. The repeat CT scan showed that there was oedema in the right fronto temporal region and this malfunciotn is purely reactionary and usually reverses once the original cause of the irritation viz, the blood reduces. It subsides with time. There was no shift of the midline. This meant that the mass effect due to the oedema was also not significant to warrant immediate surgery. It is to be noted that the two CT scans were seen by the Radiologist, Dr.Kesava Rao. In the first CT scan done on 25.3.2004, he noted that there was minimal midline shift.
In the second CT scan done on 27.3.2004 also, he noted that there was minimal midline shift. This is further confirmation of the fact that the interpretations of the two CT scans seen by two different professionals was the same.
Surgery is only performed if there is further worsening of the midline shift of the brain. This increase in the oedema was predicted and treatment was continued as before.
Opposite party no.2 further submitted that on the morning of 28.3.2004, the patient was found to be not moving the left side. His pupils were of equal size and reacting to light. He was still restless. The same observations were made by other doctors who saw him later in the day.
On 28.3.2004 opposite party no.2 had to go to Bidar. This was a programme organized by the Indian Medial Association, Bidar through Mediciti Hospital. This was organized several months prior to that day. Since the patient, Dr.Chincholi was in a critical condition, opposite partyno.2 had to decide to cancel the programme a a very short notice since there would be no one to take his place. Opposite partyn.2 examined the patient at about 2 p.m. that afternoon, so that he could see for himself whether he should cancel his programme at a very short notice since there would be no one to take his place. Opposite party no2. Examined the patient at about 2 p.m. that afternoon so that he could see for himself whether he should cancel his programme. Since the patient was moving his head to command, the oedema was localized and that there was no immediate threat to his life due to the intracranial clot oedema.
Opposite party no.2 felt that a craniotomy could be planned on 29.3.2004 after organizing the requirements for a craniotomy for a craniotomy which is a major surgery. This was also explained to the patients brother. Opposite party no.2 also felt that there was a possibility that fever may be due to aspiration pneumonia. Hence he was started on antibiotics: Inj. Magnex and INj. Flagyl. Opposite party no.2 contacted another Neurosurgeon, Dr.Rahul Lath, Consultant Neurosurgeon, Apollo Hospital, to cover in case the patients pupil dilated. This is a sign that the blood clot had become bigger. In this case he would require an urgent craniotomy. Since opposite partyno2 felt that there was no threat of such an event, he discussed the case in detail with opposite party no.3 i.e., Dr.K.Lakshma Reddy who was in charge of the SICU and told him of the plan for surgery the next day . opposite parytno2. Had told him he did not expect any imminent danger to the patients life. It is wrong to say that no neurosurgeon was involved. Opposite partyno2. Has intimated Dr.Lath that he may not be there for that evening and he was prepared to cover any neurosurgical problem.
Opposite party no.2 further submitted that it is wrong to say that no physician was contacted by Dr.Lakshma Reddy since the patient had pulmonary embolism which is known to cause high temperature and an increased heart rate. Tachycardia may be due to several other reasons which the patient also probably had such as pain, fever, restlessness. This had been the case since admission. Antibiotics were also started by this time. The opinion of a cardiologist is only sought when the patient has cardiac arrhythmias and change of blood pressure. The patient had sinus tachycardia which is usually a response to another problem and not a primary cardiac disease. He contended that Mr.Mahesh is a graduate and is a fully qualified anesthetist and intensive care technician. He is trained in cardiopulmonary resuscitation and in basic life support. He submits that the patient expired due to the pulmonary embolism and that it is wrong to blame the doctors for the patients final outcome. He denied that CVP monitoring was not done and submit that a right subclavian intravenous line was inserted. This was used to measure the Central Venous Pressure which was recoded in the case sheet on several occasions. He denies that opposite party no.3 had written the case sheet afterwards.
Opposite party no.3 had been actively treating the patient and doing his utmost to save the patients life. He was correcting IV lines, checking the fluids, performing the suctioning and trying his maximum to see that the patient lies. He submits that as such a time it is not possible to write detailed notes in the case sheet. He denies that opposite parties have miserably failed to render proper and effective medical service to the husband of the complainant no.1 and that there was gross and criminal negligence in rendering service to the patient. Therefore the opposite parties pray for dismissal of the complaint.
The complainant filed affidavit evidence reiterating the facts in the complaint and filed Exs.A1 to A8 by way of evidence. Opposite parties filed affidavit by way of evidence and got marked Exs.B1 and B2.
PWs No.1 to 3 were examined on behalf of the complainant and RWs No.1 and 2 were examined on behalf of the opposite parties.
The brief point for consideration is whether there is any medical negligence on behalf of the opposite parties in treating the husband of the complainant no.1.
We heard both sides and both sides also filed written arguments.
Ex.A1 is the legal notice dated 25.4.2004 got issued by the complainant to the opposite parties calling upon them to handover the Xerox copies of the case sheet, investigation reports and death summary. Ex.A2 is the reply dated 5.5.2004 given by the opposite party no.1. Ex.A3 is the death summary dated 28.3.2004. Ex.A4 is the case summary. Ex.A6 is the legal notice got issued by the complainant dated 8.6.2004 to the opposite party no.1. Ex.A7 is the salary certificate of the deceased dated 15.9.2004. Ex.A8 is the In-patient bill.
Ex.B1 is the progress note in which treatment rendered to the patient by the hospital. Ex.B2 is the certificate issued to Mr.G.Mahesh as anesthetic technician. There is also a testimonial filed stating that he has undergone P.G. diploma course in anesthesia technology. He has also filed a degree marks sheet of Kakatiya University.
On perusal of the material on record we observe that the facts not in dispute are that the patient is an Assistant Professor in Periodontology, Dental College Hospital in Gulbarga and the first complainant is his wife. On 24.3.2004, while riding a motor cycle at about 11 p.m. the first complainants husband fell down and sustained head injuries and was immediately shifted to Basaveshwar Hospital at Gulbarga and was treated in that hospital on that night and on the next day and thereafter he was brought to Mediciti Hospital i.e., opposite party no.1 and was admitted in the hospital at about 4 p.m. on 25.3.2004 under the care of opposite party no.2. It is the case of the complainant that opposite party no.2 started conservative treatment and failed to take cross consultation by the physician and failed to do basic blood tests like LFT, blood coagulation parameters, standard CBP, Electrolytes which are essential for any patient and failed to get baseline ECG which is essential and also failed to get opinion of another neuro surgeon and continued his conservative treatment till 28.3.2004 and the condition of the patient deteriorated. It is also the case of the complainant that opposite party no.2 visited the patient only once in 24 hours though the patient condition was critical and shifted to SICU on 25.3.2004 and on 28.3.2004 in spite of repeated requests opposite party no.2 doctor left for Bidar without entrusting the patient to any other competent doctor. It is also not in dispute that no postmortem was conducted and that the death was not recorded as a medico legal case and the body was handed over to the attendants. Opposite party no.1 denied that opposite party no.2 had visited the patient only once in 24 hours and that he left for Bidar on 28.3.2004, and also denied that he did not entrust the patient to any competent doctor to take care of the treatment. Opposite party also denies that protection of the airway would have reduced intra-cranial pressure and in fact it is usually if the patient has an in dwelling orotracheal tube, that actually irritates the patient more and causes a further rise in intracranial pressure. He submits that there is always a doctor on duty who is available round the clock in SICU and the duty doctor who recorded that evening at 7 p.m. that all the vital parameters were stable, informed opposite party no.2 on telephone and hence continued the same treatment. On the morning of 26.3.2004 the patient was found to have low grade temperature, opposite party no.2 submits that he advised him to start the patient on tepid sponging and that an internal medicine specialist was there to attend the patient. Since fever is a common complication after head injury internal medicine specialist was not consulted. We do not find any force in this explanation of the opposite party and we are of the considered view that when a patient who suffered head injury was in SICU and when fever had developed and persisted, an internal medicine specialist or a physician ought to have been consulted. The contention of the opposite party that ECG, 2D Echo, ultra scan of abdomen and LFT were not done and cardiologist consultation and physician consultation was not taken since the patient was admitted with a head injury is unsustainable. There is no medical literature to support the contention of the opposite parties that these tests are totally irrelevant to the condition of the patient. The contention of opposite parties that a physician was not consulted; because a physician is not needed for a patient with head injury is not sustainable.
Opposite party no.2 admitted that he reviewed the patient and found no change in neurological status and advised to continue the same treatment. The patient was flexing and extending the muscles in the legs normally and there was no Deep Vein Thrombosis (DVT). Opposite party no.2 in his written arguments submits that DVT in the legs is the important cause of pulmonary thrombo-embolism (PE) which is a condition where the clot from the leg moves upto the head. This leads to blockage of blood in the main blood vessels which may lead to cardiac arrest and death. The contention of the complainant that had the patient been given TED stockings the DVT would not have occurred in the legs, was resisted by the opposite parties on the ground that the TED stockings do not prevent DVT occurring in the legs and also that DVT can occur only in the veins of the legs and that nursing staff was asked to compress the calf muscles manually and to change the position of the patient every 2nd hour. We observe from the case sheet that such instructions to the nurses is absent and the nurses notes do not show that every two hours position of the patient was changed or that any steps were taken to control DVT while it is an admitted fact that TED stockings were not given.
It is also an admitted fact that on 28.3.2004 opposite party no.2 had gone to Bidar. Opposite party no.2 submitted that at the time of his departure, since the patient was moving his hand to command, the oedema was localized and that there was no immediate threat to his life due to the intracranial clot oedema. It is stated in the written arguments that opposite party no.2 felt craniotomy could be planned on 28.3.2004 after examining the requirements for craniotomy which is a major surgery this was also explained to the patient brother. It is also stated in the written arguments that opposite party no.2 felt that there was possibility that fever may be due to aspiration pneumonia and therefore he was started on antibiotics and opposite party no.2 contacted another neuro surgeon in case he would require urgent craniotomy. When it is an admitted fact that opposite party no.2 felt there may be a threat of an event where emergency craniotomy has to be conducted and submits that craniotomy is admittedly a major surgery, he ought to have been present or entrusted it to another neuro surgeon. The case sheet does not reflect that another neuro surgeon had closely monitored and recorded the critical condition of the patient or has taken any steps to post the patient for surgery. It is the contention of the complainant that the surgery was postponed two days only because the surgeon wanted to go out of station leaving the patient unattended. PW3 who is also a doctor who previously worked in ICU in the same hospital had deposed in favour of the complainant stating that the second CT scan of the brain was taken on 27.3.2004 and it shows increase of oedema on the right side of the brain, so surgery should have been done on the same day and not on 29.3.2004. PW3 further deposed that he had complained to the opposite parties about improper treatment though he was previously under the employment of opposite party no.1.
It is also deposed by opposite party no.2 doctor that it is not true to suggest that the notes in the case sheet will not be made contemporaneously. He denied whether anesthetist was present in person in the ICU at that time and also deposed that he had no idea whether TED stockings were put on the patient or not and contended finally that the cause of the death was due to Pulmonary Embolism. We observe from the case sheet that on 28.3.2004 it is written S/B that is seen by Dr.Laxma Reddy and notes were continued by anesthetist. Opposite party no.2 in his cross examination stated that the case sheet was written after the entire treatment was over and the patient had died. We find force in the contention of the complainant that to circumvent the allegation of having not seen the patient when he was called as soon as the patient developed complications the notings were made as if he had seen the patient at 7.15 p.m. The learned counsel for the complainant submitted that, if Dr.K.Laxma Reddy had seen the patient at 7.15 p.m. and he was there attending on him upto 9.45 p.m. there was no necessity to note seen by K.Laxma Reddy after the noting of the Cardiologist at 9.50 p.m. and after the noting the patient was declared dead at 11.35 p.m. We find force in the argument of the learned counsel for the complainant that by the time opposite party no.3 saw the patient, the patient was on ventilator and noting of opposite party no.4 that Laxma Reddy was informed and that he advised ventilation clearly shows that the said doctor was not present in the hospital at 7.15 p.m. We note that when the patient was in an emergency situation care ought to have been taken to see that a neuro surgeon and his team were present in SICU. With reference to duties of the doctors to the patient, the National Commission in TARUN THAKORE v. Dr.NOSHIR M.SHROFF in O.P.No.215/2000 dated 24-9-2002 reported in Landmark judgements on Consumer Protection P-410 held as follows:
The duties which a doctor owes to his patient are clear. A person who holds himself out ready to give medical advise and treatment impliedly undertakes that he is possessed of skill and knowledge for the purpose. Such a person when consulted by a patient owes him certain duties, viz., a duty of care in deciding whether to undertake the case, a duty of care in deciding what treatment to give or a duty of care in the administration of that treatment. A breach of any of those duties gives a right of action for negligence to the patient. The practitioner must bring to his task a reasonable degree of skill and knowledge and must exercise a reasonable degree of care. Neither the very highest nor a very low degree of care and competence judged in the light of the particular circumstances of each case is what the law requires In INDIAN MEDICAL ASSN. v.
V.P.SHANTHA (1995) 6 SCC 651 the court approved a passage from Jackson and Powell on Professional Negligence and held that The approach of the courts is to require that professional men should possess a certain minimum degree of competence and that they should exercise reasonable care in the discharge of their duties. In general, a professional man owns to his client a duty in tort as well as in contract to exercise reasonable care in giving advise or performing services.
In Jacob Mathew v. State of Punjab reported in III (2005) CPJ 9 (SC), the Apex Court has concluded in para 48(3) as follows:
A professional may be held liable for negligence on one of the two findings; either he was not possessed of the requisite skill which he professed to have possessed, or, he did not exercise, with reasonable competence in the given case, the skill which he did possess. The standard to be applied for judging, whether the person charged has been negligent or not, would be that of an ordinary competent person exercising ordinary skill in that profession.
In Bolam v. Friern Hospital Management Committee, WLR at p.586 it is held as follows:
Where you get a situation which involves the use of some special skill or competence, then the test as to whether there has been negligence or not is not the test of the man on the top of Clapham omnibus, because he has not got this special skill. The test is the standard of the ordinary skilled man exercising and professing to have that special skill. A man need not possess the highest expert skill..It is well established law that it is sufficient if he exercises the ordinary skill of an ordinary competent man exercising that particular art In the instant case for the aforementioned reasons we are of the considered view that this duty in tort or reasonable care as per standard medical parlance was not exercised.
It is also an admitted fact that no physician was contacted by Dr.Laxma Reddy and that patient had Pulmonary Embolism which is known to cause high temperature and an increased heart beat. It is the case of the opposite parties that craniotomy was sought only when the patient has cardiac arrhythmias and change of blood pressure but in the instant case the patient had sinus tachycardia which is usually a response to another problem and not a primary cardiac disease. We do not find any force in this contention. When a patient had sinus tachycardia and is admitted in SICU and was also admittedly suffering from Pulmonary Embolism, the opinion of cardiologist ought to have been sought for. We also find force in the contention of the complainant that the patient died of pulmonary embolism and that he was not given due care in SICU by a well qualified anesthetist and was in fact treated by a technician called Mr.Mahesh. We also observe from the record filed by the opposite parties that Mr.Mahesh was indeed an anesthetist technician who was trained in basic life system worked in the department of anesthesia and critical care of SVIMS but is not a medically qualified anesthetist to have assisted a critical care patient who developed aspiration pneumonia. Not having a qualified anesthetist i.e., a medical doctor specialized in anesthesia to take care of patients in critical care suffering from Pulmonary Embolism is itself an act of deficiency of service.
There is also no evidence on record to state that postmortem was advised by the opposite party and that complainant had denied to get it done. When it is an admitted fact by the opposite party that the patient suffered from a head injury falling from motor cycle it was not even registered as an accident case and no postmortem was done to ascertain the cause of death. This also amounts to an act of negligence.
In regard to the choice of the multiplicand the Halsburys Laws of England in Vol.34, para 98 states the principle thus:
98. Assessment of damages under the Fatal Accident Act, 1976 The Courts have evolved a method for calculating the amount of pecuniary benefit that dependents could reasonably expect to have received from the deceased in the future.
First the annual value to the dependents of those benefits (the multiplicand) is assessed. In the ordinary case of the death of a wage-earner that figure is arrived at by deducting from the wages the estimated amount of his own personal and living expenses.
Further as to the multiplier, Halsbury states:
However, the multiplier is a figure considerably less than the number of years taken as the duration of the expectancy. Since the dependents can invest their damages, the lump sum award in respect of future loss must be discounted to reflect their receipt of interest on invested funds, the intention being that the dependents will each year draw interest and some capital (the interest element decreasing and the capital drawings increasing with the passage of years), so that they are compensated each year for their annual loss, and the fund will be exhausted at the age which the Court assesses to be correct age, having regard to all contingencies.
The Honble Supreme Court in the case of General Manager, Kerala State Road Transport Corporation, Trivandrum v. Susamma Thomas (Mrs) and Others, I (1994) ACC 346 (SC) = (1994) 2 SCC 176 laid down clear principles on which compensation needs to be decided: The proper method of computation is the multiplier method.
Any departure, except in exceptional and extraordinary cases, would introduce inconsistency, of principle, lack of uniformity and an element of unpredictability for the assessment of compensation.
Again it held that multiplier method involves ascertainment of the laws of dependency of multiplicand having with regard to the circumstances of the case and capitalizing multiplicand by appropriate multiplier. The choice of the multiplier is determined by the age of the deceased or that of the dependents/claimants and by the calculation as to what capital sum, if invested at a rate of interest appropriate to a stable economy, would yield the multiplicand by way of annual interest. In ascertaining this, regard should also be had to the fact that ultimately the capital sum should also be consumed up over the period for which the dependency is expected to last.
Apex Court while observing that much of the calculation necessarily remains in the realm of hypothesis in every case it is the overall picture that matters the Court must try to assess as best as it can the loss suffered, specifically observed that the chances that deceased might have got better employment or might have lost his employment or income altogether, needs to be taken into account.
The complainant has filed salary certificate which shows that the deceased was drawing a salary of Rs.15,000/- per month minus professional tax of Rs.200/- and the total amount comes to Rs.14,800/-. In addition to this the complainant has submitted that he is also having private practice earning Rs.15,000/- but no documentary evidence has been filed to substantiate this amount. Taking into consideration Rs.15,000/- per month and taking into account 1/3 of the amount to be spent towards persona use it would come to RS.15,000/- minus RS.5,000/- comes to Rs.10,000/-. Taking into consideration that he was aged about 32 years ad also the multiplier effect the compensation that can be reasonably awarded is (Rs.10,000/- X 12 = Rs.1,20,000/- per annum) Rs.1,20,000/- X 18 = Rs.21,60,000/- and also Rs.28,500/- spent towards medical expenses together with costs of Rs.5,000/-.
In the result this complaint is allowed in part directing the opposite parties to pay Rs.21,60,000/- together with medical expenses of Rs.28,500/- along with costs of Rs.5,000/-. Time for compliance six weeks.
PRESIDENT LADY MEMBER MALE MEMBER KMK* APPENDIX OF EVIDENCE WITNESSES EXAMINED For complainant PW1 Smt Deepasri Chincholi (Complainant No.1) PW2 Mr.N.Ashok Kumar PW3 Dr.Kamal Kumar For opposite parties RW1 Dr. Ramachandra Dama Raju (O.P.No.2) RW2 Dr.K.Lakshmana Reddy EXHIBITS MARKED For complainants Ex.A1 Legal notice dated 25.4.2004 Ex.A2 Reply dated 5.5.2004 given by the opposite party no.1.
Ex.A3 Death summary dated 28.3.2004.
Ex.A4 Case summary.
Ex.A5 Brochures.
Ex.A6 Legal notice got issued by the complainant dated 8.6.2004 to Ex.A7 Salary certificate of the deceased dated 15.9.2004.
Ex.A8 In-patient bill.
For opposite parties Ex.B1 Progress note in which treatment rendered to the patient by the hospital.
Ex.B2 Certificate issued to Mr.G.Mahesh as anesthetic technician.
PRESIDENT LADY MEMBER MALE MEMBER