State Consumer Disputes Redressal Commission
S. Pradeep Son Of Sri S. Pandu Age 24 ... vs 1. Nizams Institute Of Medical ... on 31 March, 2022
BEFORE THE TELANGANA STATE CONSUMER DISPUTES REDRESSAL
COMMISSION:HYDERABAD
C.C.No.209/2014
Between:
S.Pradeep,
S/o.Sri S.Pandu,
Aged :24 years, Occ:Student,
R/o.H.No.11-20, Fathenagar,
Hyderabad - 500 018. ...Complainant
And
1.Nizam's Institute of Medical Sciences,
Represented by its Director,
Punjagutta, Hyderabad 500 082.
2. Prof. D. Mukunda Reddy,
S/o.not known,
Age about: 55 years, Occ: Doctor
3. Dr.Srikanth,
S/o.not known,
Age about 45 years, Oc:Doctor,
4. Dr.N.Rambabu,
S/o.not known,
Age about 40 years, Occ:Doctor,
5. Dr.R.Parvathi
W/o.not known,
Age about 33 years, Occ:Doctor,
6. Dr.R.Babu Rao,
S/o.not known,
Age about 38 years, Occ:Doctor
O.P.nos.2 to 6 are Doctors in Department of
Plastic and Reconstructive Surgery,
Nizam's Institute of Medical Sciences,
Punjagutta, Hyderabad - 500 082.
7. The Oriental Insurance Company Limited,
Divisional Office Ill, Hyderabad
Represented by its Divisional Manager/Divisional Head
Flat No.302, 3rd Floor, Al-Karim Trade Centre,
Opp.Ranigunj Bus Depot,
Hyderabad - 500 003.
8. The Oriental Insurance Company Limited,
Chairman - cum-Managing Director,
Regd. Office A 25/27,
Asaf Ali Road,
New Delhi 110 002. .. Opposite Parties
(Opp.parties 7 & 8 are added as per order
Dt.24.11.2016 in CCIA.647/2016)
Counsel for the Complainant :M/s. Uday Vir Singh Laur
Counsel for the Opposite Parties M/s.G.Ananadam- Opp.parties 1 to6.
M/s.S.Agastya Sarma-Opp.parties 7 & 8.
CORAMI: Hon'ble Sri Justice M.S.K. Jaiswal, President,
And
Hon'ble Smt. Meena Ramanathan, Lady Member.
THURSDAY, THE THIRTY FIRST DAY OF MARCH, TWO THOUSAND TWENTY TWO.
Order:
1. This is a complaint filed by the Complainant u/s. 17(1)(a)i) of the Consumer Protection Act, 1986, praying to direct the opposite parties 1 to 8 jointly and severally to pay Rs.99,98,645/- along with interest at 18 % p.a. towards the amount paid to the opp.parties through various transactions, expenses incurred on drugs and specific diet and towards pain and suffering and mental agony etc. The complainant further prayed to direct the opposite parties jointly and severally to get the treatment of the complainant done on expenses to be borne by the opposite parties ina suitable hospital where the treatment for the complainant is available/possible within India or abroad.
2. The brief facts of the complaint are as follows:
The complainant was a student of Bachelor of Arts and a small swelling developed on his chin, on 19.1.2007. He approached opposite party no.2 the Head of Department of Plastic and Reconstructive Surgery in opposite party no.1 Hospital, who prescribed X-Ray of the Mandible Region (Chin) of the complainant. On examination of the X-ray, the opposite party no.2 diagnosed the problem as 'Vascular Malformation Chin Mandibular Region' and advised the complainant to undergo a small surgery. The complainant was admitted in opposite party no. 1 hospital on 23.1.2007 and opposite party no.3 conducted surgery on the chin of the complainant on 25.1.2007 under the supervision of opposite party no.2 and assistance of opposite parties 4 &6.
During the surgery, the opposite parties removed the mandible region (chin) bone and the jaw including the skin over the chin and the neck and six of the lower teeth of the complainant and affixed a 16 hole plate across the midline.
Subsequently, on 27.1.2007 the opposite parties removed the central segment of the mandible region (chin bone and the jaw ) including the skin over the chin and the neck and the lower teeth of the complainant and extracted a of bone from the left leg of the complainant for using as double barrelled piece and tried to fix it on chin which was unsuccessful. To overcome the flaws graft 3 coamtted in performing the first surgery, the opp.parties performed two more surgeries on 28.1.2007 and 29.1.2007.
The complainant submits that the action of the opposite parties in removing chin bone jaw, six lower teeth and skin over the chin and the neck was unwanted and without any valid reasons as the disease was only related to vascular system and not to bones. The procedure that was carried out involved removing of the chin bone and the lower teeth which come in area of specialization of either Orthodontic surgeon or Oral & Maxillofacial Surgeon but not in that of Plastic and Reconstructive Surgery and the opposite parties carried out the surgery beyond their field of expertise. Due to the negligence of the opposite parties in performing the surgery, the face of the complainant to an extent that he is unable to show his face publicly. Because of the surgery, face of the complainant was disfigured and the mouth of the complainant remains in permanent open condition. Again on 18.10.2007 further surgery on the complainant was conducted in the opp.party no.1 hospital by removing the parts of the fibula bone along with skin and peroneal vessels from his right leg for grafting purpose and it was fixed to the central segment of the mandible with plates and screws. After few months of the said surgery, there was hairy growth on the inner side of lower lip of the mouth where the skin was grafted. Resultantly the complainant started feeling uneasy and started having vomiting sensation as the hair frequently entered into his throat along with food. Again the opposite parties conducted operation on 14.6.2008 by taking out skin from the area right side of the neck of the complainant and placing it over the mandible region to form a lower flap to the mouth.
On the advise of the opposite parties, the complainant visited a Dermatologist for treatment of the hair growth on inner side of his mouth who informed that there was no possibility of any treatment to remove the hair because laser treatment cannot be done inside the mouth. As there was loss of lip competence, the complainant had to undergo another surgery for correction of his lower lip. The complainant had undergone surgeries in opp.party no.1 hospital on 30.3.2009, 6.2.2010, 11.10.2010, 28.2.2011, 6.7.2011, 14.10.2011, 4.2.2012. The complainant was admitted in the opposite party no.l for over 10 times and 13 surgeries were conducted by the doctors of opposite party no.1 and he was charged with different amounts for each surgery. In the last surgery the bone and skin which were not fixed and got infected were removed. All the surgeries conducted by opposite parties proved futile and the condition of the complainant deteriorated and he suffered physically and also underwent mental trauma since his mouth is in permanently open condition with visible upper teeth without lower lip and chin, hair growing inside the mouth and unable to eat food and he also lost opportunities of employment and probabilities of his marriage.
The complainant got issued legal notice dt.20.11.2013 to the opposite parties 1 to 6 for which reply notice dt.30.11.2013 was given denying the allegations of the complainant. The complainant submitted a complaint to A.P.Medical Council against opposite parties doctors. A.P. Medical Council sent a letter dt.3.6.2014 to the complainant advising to provide IP number.
The complainant addressed letter to opposite parties 1 to 6 funishing IP number. As there was no response from the opposite parties, the complainant was constrained to file the present complaint.
3. The Executive Registrar of opposite party no.1 Institute filed written version denying the allegations made in the complaint. Opposite parties 2 to 6 filed a memo adopting the written version of opposite party no.1.
The opposite party no.l submits that the vascular lesion in the chin of the complainant was recurrent and had been present for 8 years before admission in their hospital and he had been operated at ESI hospital for the same complaint 4 years prior to coming to them. The extent of swelling was from the skin to inside of the lower lip as per the Case Sheet history details and during the process of removal of the swelling, it was noticed that there were blood vessels from the swelling entering the central segment of the lower jaw and thus complete removal of the swelling would necessitate removal of the chin also because of the relation of the teeth to the chin it was not possible to remove the central part of the lower jaw without removing he teeth. The same was communicated to the patient's mother during the operation and she was also explained the necessity of reconstructing the lower jaw using the bone from the leg to decrease the risk to the patient on account of further blood loss, further removal of the bone and its reconstruction was deferred on the same day and the patient was shifted to the intensive care unit. Microvascular bone transfer was done on 27.1.2007. On 28.1.2007 re-exploration was done to revive the flap successfully; overnight the lap was well but as there was another vein blockage, in the morning it was decided to remove the failing bone and temporarily fix the gap with a plate on 29.1.2007.
It is true that the three microvascular surgeries left scars in the upper neck and it was decided to do skin expansion and on 11.10.2010 surgery was done for the placement of a tissue expander for increasing the amount of skin over the chin and the upper neck and after expansion process was completed which took about 3 % months on out-patient basis, the expander was removed on 28.2.2011 and the skin adjusted over the previously fixed bone graft to improve its blood supply. Hair in the mouth is consequent to transfer of the skin of the fibula for reconstructing bone and is navoidable but a secondary done to remove and surgery was replace by mucosa which is the standard procedure offered to other patients too. The opposite party submits that they have taken insurance coverage for all their medical professionals and other staff from the Oriental Insurance Company and they were covered from the professional indemnity under the insurance policy known as Error and Omission - Medical Establishment Policy and further the indemnity also applies to the clients arising out of bodily injury and by or death of any patient caused by or alleged to have been caused by or in professional service rendered by the institute or employees of the institute. The opposite party no.1 institute doctors have treated the complainant as per standard procedure and there was no negligence or deficiency of service on their part and the complaint is devoid of merits and the complainant is not entitled for any of the reliefs as prayed for in the complaint.
4. On behalf of the opposite parties 7 & 8- Oriental Insurance Company Ltd., written version filed denying the allegations made in the complaint and also contending that they have adopted the written version filed on behalf of the opposite party no.1. The opposite parties submit that on perusal and consideration of the written version of opposite party no.1 together with supporting documents marked thereon, it is evident that neither opposite party no.l nor opposite parties 2 to 6 can be held responsible or made liable for any sort of negligence since they were diligent in discharging their duties while attending on the complainant. The complainant did not produce any medical opinion or atleast any expert opinion of any of the specialists in the respective fields of medicine to sustain the aspect of alleged negligence on the part of opp.parties 1 to 6 and hence the claim of the complainant is speculative in nature. The opposite parties submit that the complaint is devoid of any merits and is liable to be rejected by holding that compensation claimed is speculative and calculated to cause wrongful loss to insurer i.e. opposite party no.7 and prayed to dismiss the complaint
5. Evidence Affidavit of the complainant as Pw. filed. Exs.A1 to A116 are marked on behalf of the complainant. On behalf of the opposite party no.1, Dr.K.Dilip Kumar, Executive Registrar of opp.party no.1 filed Chief Affidavit Evidence. Opposite parties 2 to 4 filed their evidence affidavits. Evidence Affidavit of Mr.D.Rama Mohan Rao, Dy.Manager/Authorised Signatory of opposite party no.7 filed on behalf of opposite parties 7 & 8. Exs.B1 to B5 are marked. Advocate Commissioner's Report filed after cross examining the opposite parties 3 & 4.
66. The point that requires our consideration is whether the surgeries were conducted deficiently and negligently by the opposite parties contended as by the complainant and if yes, is he entitled to the reliefs prayed for?
7. The complainant aged about 24 years and a student of Bachelor of Arts approached the opposite parties who are specialists in plastic & reconstructive surgery. As per his complaint, he submits that he developed a small swelling on his chin in the year 2006 and he approached opposite parties in the year 2007. The problem was diagnosed as "Vascular Malformation Chin Mandibular Region" and he was advised to undergo a small surgery on 23.1.2007, He further submits that during the first surgery the opposite parties removed the mandible region bone & six lower teeth of the complainant. The surgery, he claims was unsuccessful and subsequently on 27.1.2007 one more surgery was conducted. Thereafter, multiple surgeries were conducted and he is suffering from the consequences as his face is damaged and he is unable to show his face to the public.
8. We have perused the material placed on record to reconstruct the medical history of the complainant and to understand the treatment he has undergone.
Ex.Al dated 6.2.2007 is issued by the Department of Plastic and Reconstructive Surgery of Nizams Institute of Medical Sciences-Opposite party no. 1 In this exhibit, the complainant's case is diagnosed as "Vascular Malformation Chin & Mandibular Region" and in the clinical notes it is clearly recorded that he was 16 years old and presented with swelling ober (sic) chin since 8 yrs. gradually increase in size'. As per this exhibit, the complainant has been undergoing this problem for some time and has already been treated earlier at ESI hospital.
It is important to refer to Ex.A10 dated 29.12.2006 a letter from Govt. of Andhra Pradesh to opposite party no.1 hospital. In this letter, the Government has sanctioned an amount of Rs.30,000/- to the complainant to meet his medical expenses. The purpose is 'Venous Malformation of Chin'.
It is necessary to understand Venous Malformation of Chin', the medical problem that the complainant was suffering from. Venous malformations are slow flow vascular malformations, caused by abnormalities in the development of the veins. Venous malformations vary in size and location within the body. As these are vascular malformations, they are present at birth and grow proportionately with the child.
We now refer to the cross examination of Dr. R.Srikanth (Opposite 9 party no.3) as DW.1, wherein he has explained that a vascular malformation is abnormal growth after blood vessel and can extend from the skin and underlying fat right up to the bone". He has also stated that "the involvement of chin bone was an inter operative finding when it was noticed that the malformation extended into the chin". The Doctor - opposite party no.3 has also answered that Yes, it was not known that chin bone would need to be removed during the surgery".
The point that arises is, were the consequences of the surgery and reconstruction explained to the complainant or his family?
The opposite parties have submitted that consent for removal of chin bone was taken from the mother of the patient, but the consent obtained does not form part of the records. Venous malformations increase the risk of developing blood clots in the deep veins (DVT) - which is a serious medical condition. These vascular malformations do not shrink or go away without treatment. We have closely studied Ex.A16 the Out Patient medical record and on page 45 the following is recorded:
?Venous malformation of chin extending intra orally vascular malformation". DOA: 19.1.2007 DOS : 20.1.2007 The fact that the complainant was suffering from this complication was known to the family as they have approached the Govt. of A.P. as evidenced vide Exs.A10 to A12 for monetary assistance.
10. The jaw is the most common location for a facial venous malformation, but it can involve many parts of the face and can lead to:
Replacement of bones, muscles and organs/ teeth in the face. This inevitably means a a facial venous malformation may wear down bones or occupy muscles and organs in the face. Dislocation (movement) of normal structures in the face.
This can cause changes in the way the face looks leading to extensive disfigurement Severe conditions require complementary tests for the differential diagnosis between Soft Tissue or Bone Neoplasms. In the instant case there was bone tissue involvement and dental misalignment.
Arterio Venous Malformation (AVM) of the Mandible has significant potential for massive haemorrhage Treatment involves jaw resection involving bone grafting and replacement of lost teeth. On 1.4.2008 Ex.A16 page 53 following is noted:
"Xx Pt. has bad breath-Inability to close mouth completely xx".
"For lip to ascent pt. will need mucosal and skin advancement c interpositional flap"
"Plan :Nanolatrial flap".
The fact that the complainant was sulering from a complication and woulcd require multiple interventions needs appreciation. The opposite parties never assured him that one surgery would resolve the issue completely. ln the legal notice, dated 20.11.2013 - Ex.A17 reference is made to 10 surgerles undergone by the complainant. The first surgery was conducted on 27.1.2007 and last one on 4.2.2012 at the opposite party no.l hospital. The complainant has also not provided any records of the treatment and surgery he underwent at ESI prior to joining the opposite party hospital. No expert opinion has been provided to arrive at any conclusion that the opposite parties did not atend on the complainant to the best of their abilities.
11. The evidenee affidavit submitted by the opposite parties reiterates the fact that the complainant had been operated at 1ESI hospitul for the samne complaint 4 years prior to coming to opposite party no.1 hospital. Moreover, the extent of the swelling was from the skin to the inside of the lower lip as per the Case Sheet details Ex.A1. Surgical plan was to permnit complete removal of the swelling which had not been removed earlier at EsI hospital;
vascular swellings when renmoved incompletely tend to bleed continuously and this is extremely risky for the patient's survival.
12. The complainant counsel has relied on the following citation which is discussed below:
Nizam Institute of Medical Sciences vs. Prasanth S.Dhananka and others: In this case, the patient was sullering from a "Neurofibroma' which had neurological complications and warranted the involvement of a neurosurgeon. It is also noted that there was information pre operatively before both the opposite parties 2 & 4 about vertebral erosion at T4 level and affectation of vertebrae. Failure to utilize the available pre-operative clinical information and diagnostic tests like MRI & myelogram was als0 emphasized while deciding the case in favour of the complainant.
In the referred case, the entire case record of diagnostic, medical and surgical procedures pertaining to the complaint were filed and it was concluded that the attending doctors were seriously remiss in not associating a Neurosurgeon at the pre operative as well as at the stage of the operation.
However, in the case on hand, the complainant and his family were wel aware of the problem since they had approached the government for monetary help and had also undergone a procedure 4 years prior at ESI hospital and those records have not been submitted. The material on hand as provided by the complainant is not complete and the Discharge Summaries for thec multiple Surgeries, reveal that investigations were carried oul and radiology referred to.
Radiology branch of medicine means the use of imaging technology t diagnose and treat the disease. MRI Reports are not filed but that does not mean that pre operative investigation was not carried out by the opposite parties. In every discharge summary filed vide Ex.Al- A9, there is a definite reference to investigation and radiology and therefore the case on hand cannot be viewed on the same lines as the referred judgement, The opposite parties have supported their defense by relying on Kusum Sharma & Ors. vs. Batra Hospital &Med. Research dt.10.2.2010 wherein it is stated as follows "So long as a doctor follows a practice acceptable to the medical profession of that day, he cannot be held liable for negligence merely because a better alternative course or method of treatment was also available or simply because a more skilled doctor would not have chosen to follow or resort to that practice or procedure which the accused followed".
In the Venous Malformation of Chin' the radiographic appearance is quite variable and therefore unreliable as a sole basis of diagnosis. To achieve and restore near exact form and function, major reconstructive operations are involved and it is also necessary for the medical fraternity to keep the cost factor in check. It all depends on the severity of the malformation. To argue that MRI & proper diagnostic conducted is not properly tests were not substantiated by the learned counsel for the complainant. We do not find much evidence in the allegations.
13. Vascular swelling or infected swelling involving lower jaw are excised and reconstructed by plastic surgeons as orthodontists and oral surgeons do not have the expertise to do microvascular surgery. The opposite parties conducted multiple surgeries on the complainant in order to make the necessary corrections. Every microvascular procedure was successful but the fate of the bone graft would not be known for six months or so.
Vascular malformations of the mandible region are rare and challenging and requires various treatment modalities and regular follow up is involved It can take one to three years or more. Having considered the material placed on record, the opposite party doctors provided the care without being deficient or negligent. It should be borne in mind that the complainant was suffering from a major complication that required multiple procedures and negligence cannot be attributed to the doctor so long as he is his performing duties to the best of his ability. Hence, based on the foregoing discussion, wec 10 hold that the complainant failed to prove medical negligence against the opposite parties.
14. In the result, complaint is dismissed.