State Consumer Disputes Redressal Commission
Dr. D.K. Tayal vs Fortis Healthcare Ltd. on 6 January, 2016
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
Consumer Complaint No. 42 of 2010
Date of institution: 28.5.2010
Date of Decision: 6.1.2016
1. Dr. D.K. Tayal S/o Late Sh. Roshan Lal (deceased through his legal
heirs - complainant Nos. 2 to 5)
2. Dr. Rakesh Tayal S/o Sh. D.K. Tayal aged about 49 years S/o Late
Smt. Satya Tayal r/o H. No. 3119, Sector 35-D, Chandigarh.
3. Smt. Sushma Garg W/o Sh. R.A. Garg, aged about 47 years
daughter of Smt. Satya Tayal r/o H. No. 3920, Sector 29-D,
Chandigarh.
4. Dr. Rajesh Tayal S/o Sh. D.K. Tayal, aged about 46 years S/o Late
Smt. Satya Tayal r/o H. No. 3119, Sector 35-D, Chandigarh.
5. Dr. Rajiv Tayal S/o Sh. D.K. Tayal, aged about 36 years S/o Late
Smt. Satya Tayal r/o H. No. 3119, Sector 35-D, Chandigarh.
(All legal heirs of Smt. Satya Tayal)
Complainants
Versus
1. Fortis Healthcare Limited through its Managing Director, Registered
Office Escort Heart Institute and Research Centre, Okhla Road, New
Delhi 110 025.
2. Fortis Hospital Mohali Super Speciality in Heart through its Medical
Director, Sector 62, Phase 8, Mohali 160 062.
3. Dr. TS Mahant, Executive Director, Fortis Hospital, Mohali Super
Speciality in Heart Sector 62, Phase 8, Mohali 160 062
4. Dr. Amit Kumar Mandal Consultant Pulmonologist and Critical Care
Specialist, Fortis Hospital, Mohali Super Speciality in Heart Sector
62, Phase 8, Mohali 160 062
Opposite Parties
Consumer Complaint No. 42 of 2010 2
Consumer Complaint under Section 12 read
with Section 17 of the Consumer Protection
Act, 1986.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Mrs. Surinder Pal Kaur, Member
Present:-
For the complainants : Sh. B.J. Singh, Advocate
For the opposite parties : Sh. Munish Kapila, Advocate
Gurcharan Singh Saran, Presiding Judicial Member
ORDER
Complainants have filed this complaint under Section 17 of the Consumer Protection Act, 1986 (for short 'Act') against opposite parties(herein after referred as Ops) on the averments that complainant No. 1(since deceased) wass husband of late Smt. Satya Tayal and complainant Nos. 2 to 5 are her children. Wife of complainant No. 1 and mother of complainants No. 2 to 5 (hereinafter referred as 'patient') was having a pre-existing history of hyper tension and diabetes for about a decade. On 25.11.2008, she was taken to General Hospital, Sector 16, Chandigarh. After conducting X-ray and ECG, the doctors advised Echocardiography. Since it was not available there, therefore, they approached Prime Health Diagnostic Centre and Hospital, Sector 69, Mohali and Echocardiography was performed and she was advised for angiography. Op Nos. 1 & 2 claimed JCI accreditation and accordingly, they approached Op No. 2 and immediately angiography was recommended, which was conducted on 28.11.2008, which Consumer Complaint No. 42 of 2010 3 revealed a case of CAD with severe triple vessel disease (in short 'TVD'). They were referred to Op no. 3 being head of the Cardiothoracic Unit, who advocated Coronary Artery Bypass Grafting (in short 'CABG'). The CABG was conducted upon the patient on 3.12.2008. After surgery the patient was moved to surgical intensive care unit. Patient was extubated on 4.12.2008. On 5.12.2008, the patient was well oriented and even sitting on the bed side chair. On 6.12.2008, it was reported that the patient had developed high grade fever and her blood samples were sent for culture testing. On 7.12.2008, the condition of the patient was critical. On 8.12.2008, she was tested positive for MRSA infection in the tracheal secretions and specific antibiotic therapy was started. MRSA is a hospital acquired infection. Then Op No. 2 introduced Op No. 4. However, despite alleged appropriate antibiotic regimen, the condition of the patient failed to improve and she was shifted to the ventilator with the consent of the complainants. On 10.12.2008, Ops detected the patient with an other infection called Candida and appropriate medication was started. On 16.12.2008, tracheostomy was conducted. On 23.12.2008, the patient was diagnosed with E-Coli infection in the respiratory tract. This was followed by discovery of Acinetobacter, which is also a hospital acquired infection in the blood of the patient on 27.12.2008. On 7.1.2009 Op No. 2 reported the occurrence of Sternal Wound Dehiscence i.e. separation of the Sternum (Breast Bone), which was duly closed after the CABG with loss of sutures just about 1 month and 3 days post surgery, which augmented the chances of infection of the surgical site and delay in Consumer Complaint No. 42 of 2010 4 recovery. On 14.1.2009, an other sinister hospital acquired infection called as Stenoerophomonas Maltophilia was detected. The complainants alarmed Ops of lack of coordination and critical care as is expected from world class medical facility claimed by Op No. 2 vide their representation dated 15.1.2009, which was duly acknowledged by Op No. 2 and remedial measures were promised but actually nothing was done. On 23.1.2009, consent was taken from the complainant for minor surgery, however, a major surgery was performed under general anaesthesia by Op No. 3 with the assistance of Dr. K.M. Kapoor whereby the infected sternum bone was removed and Flap surgery was done. On 30.1.2009, it was reported that the general condition of the patient was better but on 3.2.2009, it was reported that patient was positive for Klebsiella Pneumonia, an infection which breeds inside life support systems and is passed to the patient. On 17.2.2009, it was again reported that the patient was reinfected with Acinetabacter, which was detected in Mediastinal Fluid and thereafter the patient was shifted to MICU and was put on ventilator support. On 25.2.2009, the patient was detected with an other acquired infection called as Pseudomonas, which was found positive in her tracheal secretions. Since the day of admission, the patient was suffering one after the other hospital acquired infections and Ops had failed to reprieve from recurring hospital acquired infections. The patient was admitted on fixed package basis and for 101 days, the complainants paid a sum of Rs. 5,74,900/- and other amount of Rs. 3,45,326/- was spent on medicines for the period 30.12.2008 to 5.3.2009. On 6.3.2009, the patient was shifted to Consumer Complaint No. 42 of 2010 5 PGIMER, Chandigarh. The patient was managed very aggressively there and ventilator was weaned off on 14th day and was discharged in a stable condition. On 16.4.2009, after a gap of 1 month and 7 days, the patient, who was severely immune-compromised at Op No. 2 had suffered recurring hospital acquired infections and again developed symptoms of fever and shortness of breath was admitted to GMCH, Sector 32, Chandigarh but due to severely immune compromised condition resulting directly and attributable to the various episode of the hospital acquired infections acquired at Op No. 2 passed away on 19.6.2009. Due to various hospital acquired infections, the patient also contacted bed sores, which proved that Ops were grossly negligent and indulged in severe deficiency in service. Hence, the complaint with the direction to the Ops to pay a sum of Rs. 11,74,345/- alongwith interest w.e.f. the respective dates of payments and interest calculated upto 15.5.2010 i.e. Rs. 2,46,552/- till realization, compensation of Rs. 2,00,000/- each to the five complainants for causing avoidable mental and physical harassment, compensation of Rs. 2,00,000/- each to all the complainants as punitive damages and Rs. 33,000/- as litigation expenses.
2. The complaint was contested by the Ops, who filed written reply/version taking preliminary objections that as per the report of World Health Organization, it has been found that all the hospitals had incident of hospital acquired infections called as nosocomial infections. 24 patients out of 100 patients suffered from one or the other hospital acquired infection and no country has been able to solve it. Approximately 30 to 40% worldwide have this Consumer Complaint No. 42 of 2010 6 problem whereas 10% in developed countries and 20% in European Countries. Sufferance of nosocomial infections in post CABG is in no manner indicative of any medical negligence. Even the Doctors of PGI acknowledged factum of aggressive management and treatment by Op Hospital in their report, due to which, the patient was able to recover in PGI. The source of nosocomial infection is not necessarily from the hospital. Despite infection controlled protocols there is likelihood of acquiring infections in any hospital. Hospital acquiring infection can be acquired due to patient risk factor, organizational risk factors and latrogenic factors. Op hospital provides a state of the art medical speciality institution, which has set the standard for medical care in Northen India. The patient had suffered a serious bypass operation and was severally immunocompromised and was admitted in ICU post a high risk cardiac surgery, which made her susceptible to grow infections, which other better immunity patients may not have grown in similar circumstances. Best possible post operative care was given to the patient. All the times, complete cover from the organizational risk factors as well as the iatrogenic risk factors was given to prevent infections. All prevention bases clinical protocols were followed by Op hospital. Only 1/3rd of the nosocomial infections are preventable. Op hospital has established infection control department and has framed infection control policy and programme which gives specific responsibility to specific individual Doctors for compliance of infection control protocols. The patient had come to Op hospital on 26.11.2008. She was aged 63 years female and was suffering from diabetic and hyper tension for the last 10 years. Consumer Complaint No. 42 of 2010 7 Angiography was conducted and it was found that she was suffered from Tripple Vessel Disease, severe PAH, LV dysfunction, Left Ventricular failure, Hematunia and poor target vessels having acute inferior wall myocardial infraction (non thrombolised) with left Ventricular Failure, Left Ventricular Disfunction, Left Ventricular Disfunction and severe PAH. On the basis of investigation, it was decided to go for surgery that CABG and risk involved were explained to the patient and attendants CABG was done on 3.12.2008, which was performed by Dr. T.S. Mahant, Dr. Ambuj Chaudhary and Dr. Deep Khurana, who are renowned Doctors in the field of Cardiovascular Surgery. During the surgery, it was found that the patient had very poor target vessels. Two diseased vessels were bypassed successfully but 3rd vessel was very badly diseased and occluded and it was not possible to go bypass for 3rd vessel. The post operative ventilation support was given to the patient on 4.12.2008. On 5.12.2008, the patient developed abdominal distention. Immediately blood culture was ordered. It was found that the patient had developed MRSA infections, upon which Critical Care Specialists were consulted and required treatment measures were explained to the patient and relatives. Higher sensitivity antibiotic was given and infection to the patient was controlled. Ultrasonography was conducted, which revealed gaseous distention. Although the patient had improved due to the efforts of the Doctors but she still needed ventilator support and on 13th post operative day, she was put to ventilator support and appropriate nutrition was also started. Since the immune system was weak, therefore, she contracted multiple Consumer Complaint No. 42 of 2010 8 nosocomial infections during her stay in the hospital. The progress and treatment was effectively controlled by the concerned specialists. All possible care was taken. It was also insured that environment provided to the patient was infection free and sanitized. The patient had developed sterna wound dehiscense, which is known complication of heart surgery. Appropriate antibiotics were given to the patient to control the infection. On merits, admission of the patient in Op hospital was admitted. Op hospital was accorded with two prestigious accreditations, which are JCI and NABH. Patient had suffered a heart episode 4 years back. On coming to Op hospital, angiography was conducted. The patient had suffered myocardial infarction on 25.11.2008. She was initially taken to General Hospital, Sector 16, Chandigarh and then to Prime Heart Diagnostic Centre and was admitted to Op Hospital on 26.11.2008. After test, CABG TVD was conducted. On 6.12.2008, the patient had developed high grade fever alongwith distention in abdomen. The Doctors found that the patient bowel sounds were audible, though sluggish. The patient was found to have developed labour breathing with crepts in chest. On 9.12.2008, the blood sample had acquired MRSA. MRSA can cause fever in person outside hospital as well. It was denied that MRSA breeds in hospital with poor infection control mechanisms and protocols. Out of total 605 CABG patients, 131 had acquired 179 nosocomial infections, out of 26% had multiple nosocomial infections. The study further disclosed that females are at higher risk. Other risk factors included long duration use of ventilator, administration of post operative antibiotics, duration of urinary catheterization, duration of Consumer Complaint No. 42 of 2010 9 surgery and length of stay in hospital. The patient in this case was female, who had undergone heart bypass surgery with multiple surgical wounds, catheterization, on subscribed post operative antibiotics and patient was severally immunologically compromised, therefore, the patient was at high risk to acquire multiple nosocomial infections. Op hospital had taken appropriate measures according to hospital guidelines formulated according to International Guidelines of JCI and NABH to control hospital acquired infections and it was subject to routine audit and measures to strict control to provide a sanitary and sterile environment for patients in the ICU. The consultation of Pulmonologist and critical care specialist was taken as and when required appropriate by Post Operative Intensive Care team. The patient and nurse ratio is 1:1 and Doctor and patient ratio is 1:2. Moreso, the visitors are allowed very briefly to see their patients that too after wearing appropriate gowns, gloves and cleaning hands. To control MRSA, Op No. 4 correctly advised and administered the appropriate treating antibiotics and it was successfully controlled. The patient was put to ventilator and doctor may repeat trials to wean the patient off the ventilator with the hope that the patient on her own strength be able to breath normally. Such numerous trials failed initially but Ops were successful to wean off the ventilator lateron. Due to prolonged ventilator and other risk factors referred above, she grew infection called Candida, which is yeast infection. 35% of human beings had Candida infection in their life. The appearance of Candida is not only inside hospitals but it results more immunologically compromised patients for which anti fungal Consumer Complaint No. 42 of 2010 10 medication was required and appropriate medicines were given. On 16.12.2008, the patient had displayed improvement in her ventilattory parameters and was feeling better and off inotropes, which was sign of improvement in the hemodynamic condition. However, her abdominal distention persisted for which Gastroenterologists was consulted and endoscopic decompression was planned and about two litres of faecal matters was aspirated from the patient's digestive system. Then tracheal secretions grew E. Coli, which again is a common pathogen acquired by patients in ICU E.Coli is a bacteria, which is normally found in large bowel. It is most common cause in urinary tract infection. Appropriate antibiotics were immediately given to treat this infection. Periodical cultures were repeated as per protocols. Since the patient immune system was weakened due to that infection was contracted. It does not indicate any negligence in any manner on the part of Doctors and Nurses. Bed sores were treated through the regimen of Alpha Bed, changing the sleeping position, pillows etc. and other measures as per protocol, which are exhibited in the Nurse's reports. On 27.12.2008, acinetobacter infection was found in the blood culture and timely treatment was given. The complainant has potrayed a false projection as if all these infections were being contracted by the patient due to omission/negligence on the part of the Doctors. Otherwise such like infections were common even in best hospitals. The patient had developed sternal would dehiscense. The patient was over 60 years of age having diabetic for the past 10 years and it is common complication of the heart surgery. The wound was not healing and Consumer Complaint No. 42 of 2010 11 only way of closing it was by plastic surgery for which the consultation of Dr. KM Kapoor was taken and she was planned for debridement and flag cover, which was done on 23.1.2009. It was assisted with the problem of diabetic and infection. On 14.1.2009, Stenotrophomonas moltophilia was found in the blood culture for which appropriate antibiotics were prescribed. It occurs to the patient with weakened host defences. By the efforts of the Doctors and the diligent attentive care, the infections were correctly identified and promptly arrested and controlled. Lateron the patient was shifted to PGI and in the PGI she was weaned off the ventilator and was in a stable condition. This was possible only because of diligent care, aggressive management of complications and monitoring, she received at Op hospital which provided basis for her discharge lateron from the PGI. It was denied that the stay of the patient was prolonged to cause financial burden upon the complainants. It was denied that behaviour of the hospital staff was rude. It was admitted that Pseudomonas was found positive in tracheal secretions and its appropriate treatment was given. It was denied that all infections occurred were either predictable or preventable. Consent of the patient/complainants were taken for every procedure, therefore, it was denied that the stay was prolonged purely for commercial considerations whereas the complainants were fully aware that the best treatment was provided to the patient. The package of surgery is for 8 days for coronary bypass and after that the patient was to make the payments according to the treatment. It was denied that the payment was illegally taken over and above the package charges. Consumer Complaint No. 42 of 2010 12 After shifting the patient from Op Hospital she was admitted in PGI and after improving her condition, she was discharged. After a gap of one month, she again faced the problem and was admitted to G.M.C.H., Sector 32, Chandigarh, where she expired. The complainants have not placed on the record what were the diagnosis and what treatment was given in those hospitals and what were the reasons for her death. Case involves complicated questions of fact and law. Treatment was given to the patient according to the standard medical practices. In case she received some hospital infections that were due to weak immune system of the patient. The moment it was found that she was having nosocomial infection, she was isolated from the other patients and was kept in the corner bed area of the ICU. There was no negligence on the part of the Doctors of the Op Hospital and no deficiency in service on the part of Op Hospital. Complaint is without merit, it be dismissed.
3. The parties led their respective evidence in support of their contentions.
4. In support of his allegations, the complainants had tendered into evidence affidavit of Dr. Rajiv Tayal Ex. C-A, letter to Fortis Hospital Ex. C-2, discharge on request summary Ex. C-3, adhoc bill Ex. C-4, detailed bill Ex. C-5, PGI Discharge and Follow up card Ex. C-6, death report Ex. C-7, expenditure during treatment Ex. C-8. On the other hand, Ops have tendered into evidence affidavit of Deepak Saini, Manager, Medical Records Ex. Op-A, medical record Ex. Op-1, affidavit of Abhijit Singh Ex. Op-B, JCI Accreditation Certificate Ex. Op-2, NABH Certificate Ex. Op-3, Fortis Preventive Consumer Complaint No. 42 of 2010 13 Maintenance Schedule Ex. Op-4, CSSD-illance report Ex. Op-5, Test certificate Ex. Op-6, Environmental Monitoring Ex. Op-7, affidavit of Dr. T.S. Mahant Ex. Op-C, Coronary Angiography Report Ex. Op-8, Discharge on request summary Ex. Op-9, Cardiac History Ex. Op-10, High Risk Informed Consent Ex. Op-11, Cardiac Operation Theatre Notes Ex. Op-12, Complicated Sterna Dehiscence Journal Ex. Op-13, Sternal Wound complications Ex. Op-14, Final summary sheet Ex. Op-14A, reports Ex. Op-14B, affidavit of Dr. Amit Kumar Mandal, Pulmonologist and Critical Care Specialist Ex. Op-D, Medical Literature Preventing Nosocomial Infections Ex. Op-15, Nosocomial Infections Ex. Op-16, Infection Control Policies Ex. Op-17, Ventilatory Support Ex. Op-18, Impact of Nosocomial Infections Ex. Op-19, Multiple Nosocomial Infections Ex. Op-20, Eur J Cardiothorac Surg Ex. Op-21, Relations between under Nutrition and Nosocomial Infections Ex. Op-22, Nosocomial Infection Ex. Op-23, Frequency Pattern and Etiology Ex. Op-24, Frequency Pattern and Etiology of Nosocomial Infection Ex. Op-25.
5. We have heard the counsel for the complainants Sh. B.J. Singh, Advocate and counsel for Ops Sh. Munish Kapila, Advocate and have carefully gone through the oral as well as written submissions submitted by the counsel for the complainants.
6. In the written submissions the counsel for the complainants has stated that there is interpolation in the record before it was summoned by the Commission because the Discharge Summary supplied to the complainants (Ex. C-3) is at variances with the discharge summary submitted by Ops as Ex. Op-9. He has Consumer Complaint No. 42 of 2010 14 further referred about some dates about the bed sores and abdominal distention. These will be discussed when we take up the bed sores and abdominal distention. We have gone through the discharge summary filed by the complainants as well as Ops, the only difference between both is that in Ex. Op-9, there is no reference of reports attached to it whereas in Ex. C-3, some attachments have been referred, otherwise contents of both the reports are the same. We are mainly concerned with the contents of the report. In case some attachments have been referred in the report supplied to the complainant, which is not on the reports submitted by the Ops, the fact is that these were written in hand whereas the discharge summary report is computerised, therefore, it is just possible that when computerized discharge summary was supplied to the complainants then attachments were referred otherwise it will not have any bearing on the case of the complainants with regard to determination of case of medical negligence/deficiency in service on the part of Ops.
7. It has been further argued by the counsel for the complainant that hypothyroidism to which the patient was suffering was not detected in Fortis Hospital, pleural infection was not tackled in Op Hospital. On 3.12.2008 the fasting sugar of the patient was 213 but no treatment was given. However, counsel for Ops has argued that these points were not taken up by the complainant in his complaint and in case no such pleadings are there on behalf of the complainant then its reply was not filed by Ops, therefore, the complainants cannot taken any point in the arguments, which was not Consumer Complaint No. 42 of 2010 15 pleaded. He has further stated that the complainants had moved an application for amendment in the complaint but for the best reasons known to them they had withdrawn this application on 13.2.2013. In case we go through the pleadings as pleaded in the complaint, they have mainly referred about hospital acquired infections i.e. MRSA, Candida, E-Coli, Acinetobacter, Sternal Wound Dehiscence, Stenoerophomonas Maltophilia, Klebsiella Pneumonia, Pseudomonas. The complaint is silent with regard to hypothyroidism, pleural effusion or sugar of the patient on 3.12.2008. It is well settled principle of law that no point can be raised at the time of arguments, which has not been pleaded in the complaint. The counsel for the complainant was unable to convince before this Commission how he can raise these points, which have not been pleaded by him in his complaint. Same is the position with regard to abdominal distention.
8. Mainly as stated in the complaint, the concern of the complainant is with regard to the hospital acquired infections, which prolonged the treatment of the complainant in Op hospital. In case these hospital acquired infections would not have contracted to the patient then the patient could have been well within a period of one week because package for the CABG is given by Op hospital was for just 8 days because in normal condition patient recovers within 8 days. In the complaint, he has referred about the status of Op hospital, which has JCI accreditation and NABH, which is also admitted by Op in their pleadings and necessary certificates have been placed on the record. Ex. Op-2 is the certificate issued by Joint Commission International in favour of Fortis Hospital, Mohali India for Consumer Complaint No. 42 of 2010 16 the period 15.6.2007 to 14.6.2008 and another for 24.7.2010 to 23.7.2013 and then 20.7.2013 to 19.7.2016. Ex. Op-23 is the certificate of accreditations given by National Accreditation Board for hospital and Heart Care providers and it was valid upto 15.6.2014. It has been argued by the counsel for the complainant that in case the status of the hospital was of International level then such type of hospital acquired infections should not be there to the patients. He has referred that on 8.12.2008 the patient acquired MRSA. Its culture report referred as Ex. Op-1 stated as under:-
"Culture shows growth of staph aureus(MRSA) after overnight incubation."
Ex. Op-B is the affidavit of Dr. Abhijit Singh, Facility Director, Fortis Hospital, Mohali and Ex. Op-C is the affidavit of Dr. T.S. Mahant, Director CTVS, Fortis Hospital, Mohali. Dr. Abhijit Singh in his affidavit has stated that on the basis of culture report dated 9.12.2008, MRSA was positive. On 10.12.2008 other type of hospital acquired infection, namely, Candida was found on the basis of test of Tracheal Secretions wherein the final report its has been referred as under:-
"Culture shows growth of non albicans candida SPP. After overnight incubation."
It is so admitted in the affidavits of Abhijit Singh, Facility Director Ex. Op-B and Dr. T.S. Mahant, Director CTVS of Op hospital. Another hospital acquired infection E Coli was found. In report dated 21.12.2008 in the tracheal secretions, growth of Esch, Coli after Consumer Complaint No. 42 of 2010 17 overnight incubation. It was again repeated in the test dated 2.1.2009 of Tracheal Secretion and final report is as under:-
"Culture shows growth of Acinetobacter Baumannii/Haemolytius and Esch Coli. After 24 Hrs of Incubation."
Other hospital acquired infection Acinetobacter was detected in report dated 25.12.2008 when blood culture test was conducted and its remarks are as under:-
"Acinetobacter Baumanni Resistant : Co-Trimoxazole, Cefepime, Tobramycin, Ticarcillin-Clavulanic Acid."
It was also found in an other blood culture referred as Ex. Op-1 wherein it was observed as under:-
"Acinetobacter Baumannii/Haemolyticus."
It was further found in the test of Tracheal Secretion dated 2.1.2009 and again on 11.1.2009. It was again found on 15.2.2009 in wound culture. An other hospital acquired infection is 'Klebsiella Pneumonia' was detected. A reference can be made to the reports dated 4.2.2009, 15.2.2009 and 23.2.2009. An other hospital acquired infection 'Pseudomonas Aeruginosa after overnight incubation' was detected in reports on 24.2.2009 & 25.2.2009 referred as Ex. Op-1. An other hospital acquired infection 'Enterococcus Faecalis' was detected on 27.2.2009 (Ex. Op-1) and the report is as under:-
"Culture shows growth of Enterococcus faecalis after overnight incubation. Sensitive to Vancomycin."
Then another infection 'Stenoerophomonas Maltophilia' was detected on 1.11.2009(Ex. Op-1). It has been argued that MRSA is caused by strain of bacteria that becomes resistant to antibiotics used to treat Consumer Complaint No. 42 of 2010 18 other Staphylococcus infection. It is associated with invasive procedure or device as intravenous tubing, IV catheters, suction tips etc.. It can be from Tabletops hospital beds, equipments etc.. Candida infection is a fungus, which is normally present in skin and mucous present membranes of body as mouth, vagina, rectum, pharynx, oesophagus etc. It can become infectious when there is change in body environment. E-Coli infection are bacteria normally found in digestive tract of patient. In hospital settings in a immunocompromised patient can cause nosocomial pneumonia by aspiration of tracheal secretion in patient, who have been colonized by this bacteria. This pneumonia acinetobacter infection is mostly resistant to drugs leaving very few therapeutic options. Prolonged length of stay in ICU settings, ventilator assisted respiration, exposure to drugs, invasive procedures are main risk factors. Klebsiella Pneumonia is bacteria that causes different type of healthcare associated infections such as pneumonia-cum- bloodstream infection. Pseudomonas infection is normally caused in patients with compromised immune system. Long hospitalization and life threatening pseudomonas infection. Counsel for the complainant has further referred to medical literature of MJA Practice Essentials on Infectious Diseases wherein 'Common Hospital acquired infections have been referred as under:-
"Hospital-acquired infections cover a wide spectrum, including septicaemia and respiratory tract infections. Common hospital- acquired infections that may present to community practitioners Consumer Complaint No. 42 of 2010 19 are those associated with urinary catheters and intravenous cannulise, and surgical wound infections."
The programme to prevent hospital acquired infection have been stated as under:-
"5. Components of a program to prevent hospital-acquired infection Practitioner behaviour Compliance with hand washing protocols Use of aseptic technique for insertion of intravenous and urinary catheters Compliance with guidelines on antimicrobial use Patient Care Short hospital stays Early removal of invasive devices Isolation of infectious patients Hospital infrastructure and policies Adequate staff numbers Staff vaccination (eg. Hepatitis B, varicella-zoster, tuberculosis and influenza) Sharps policy Adequate sterilisation and disinfection of surgical instruments and endoscopes Infection control team Infection control programme Active surveillance for hospital-acquired infection Molecular biology laboratory"
Consumer Complaint No. 42 of 2010 20
On MRSA he has referred to research paper of 'Indian J Med Res 137, February 2013' wherein the percentage of MRSA in Fortis Hospital, Mohali has been mentioned as 43% whereas in Government Medical College & Hospital 38% and in Postgraduate Institute of Medical Education & Research, Chandigarh 36%. In case the hospital of Ops is of international standard then the hospital acquired infection should be according to the international standard. In the written reply filed by Ops, it has been mentioned in the preliminary objections that nosocomial infections are found in all hospitals in 10% in developed countries, 20% in European hospitals and 30% to 40% in worldwide hospital whereas MRSA infection in Fortis Hospital as per the reference referred above is 43%.
9. No doubt that Op hospital may have a department to control hospital acquired infection but mere creation of the Department is not sufficient. What actual work was done by the hospital during that period is relevant. The hospital has placed on the record Ex. OP-7 Environmental Monitoring in November, 2008. They have further placed on the record Ex. Op-15 'Preventing Nosocomial Infections'. Otherwise no other document with regard to its control during that period has been placed on the record. Whereas counsel for the Ops has stated that no doubt that hospital acquired infections as pointed out by the counsel for the complainants were found in the patient during the treatment in the hospital but there are different parameters for every patient, who may acquire the hospital acquired infection. It depends upon immune compromised status of the patient. Independent risk factors for the development of a nosocomial Consumer Complaint No. 42 of 2010 21 infection were identified as duration of mechanical ventilation, postoperative empiric antibiotic administration, the duration of urinary tract catheterization and female gender. The study disclosed that females are at higher risk. The patient in this case was female, who had undergone various heart bypass surgery with multiple surgical wounds, catheterization, on subscribed post operative antibiotics and patient was severally immunologically compromised, therefore, the patient was at high risk to acquire multiple nosocomial infections. Therefore, it is not necessary that all these infections had acquired due to improper upkeep of Op hospital. He has further stated that as and when any infection detected immediately control was taken where there was a need of any specialists, they were consulted and some of the infections were recovered but due to immune compromised status of the patient, it was acquired one after the other infection. Ultimately, the patient was got discharged on the request of the complainants and she was shifted to PGI and within a period of one month, patient was all right. In fact the foundation was laid by treatment given by Op Hospital and there was no finding given by PGI that the treatment given by Op Hospital to treat this hospital acquired infection was not appropriate. Even in the complaint filed by the complainant or during the course of arguments, the counsel for the complainant was unable to convince before this Commission that the treatment undertaken by Op Hospital was defective. Therefore, so far as the line of treatment taken by the Doctors, the counsel for the complainant could not find any negligence on the part of the Doctor. Consumer Complaint No. 42 of 2010 22
10. However, the main point again remains for determination whether the atmosphere or administration of the hospital was sufficient to check hospital acquired infections, whether proper precautions were being taken by Op Hospital. In case it is not so then certainly, OP Hospital is responsible for that. On the one side Op hospital is proclaiming itself to be hospital of International Standard because it has the accreditation from JCI and NABH, which is valid upto the date of treatment and the complainants had spent a sum of Rs. 5,74,000/- as hospital charges and Rs. 3,45,326/- was spent on medicines. In case hospital is charging such a high rate of hospital admission/treatment charges then they are required to give appropriate service condition at least to save the patient from hospital acquired infections. Take an example of MRSA, as per the written statement filed by Ops in para No. 1 of the preliminary objections, it has been mentioned that nosocomial infections are found in all hospitals in 10% of patients in developed countries, 20% in European Hospitals and 30 to 40% in worldwide hospitals whereas in the case of Fortis Hospital, case of MRSA, it was 43% as per the study of 'Indian J Med Res 137, February 2013', therefore, this type of infection was more than even in the hospitals of developing countries. In Chandigarh even Government Medical College & Hospital has less than MRSA infections i.e. 38% and PGIMER, Chandigarh 36%. In case Public Sector Hospital had less percentage of MRSA infections then at least private hospital, who claimed itself to be of international standard then percentage of MRSA should be less than those hospitals. No doubt they have created their own Department to Consumer Complaint No. 42 of 2010 23 control the nosocomial infection but mere creating the department is not sufficient. What actions they have been taken during those days when this patient was admitted in the hospital has not been placed on the record.
11. Sources of Hospital Infections can be as under:-
"SOURCES OF HOSPITAL INFECTIONS For an infection to occur in the hospital the prerequisites are:
(a) A susceptible host.
(b) A microbe capable of producing an infection.
(c) An environment that is congenial for the multiplication of
the microbe.
12. Various combinations of four main factors influence the nature and frequency of infections. These are as under:-
(i) Low resistance of the patients
(ii) Contact with infectious persons
(iii) Contaminated environmental sites
(iv) Drug resistance of endemic organisms
and the inanimate environment of the hospital that acts as an important source comprises of:-
(a) Contaminated air, water, food and medicaments
(b) Used equipments and instruments
(c) Soiled linen
(d) Hospital waste (Bio medical waste)
13. Bed sores were also detected on 20.12.2008 and pre-
nursing care plan sheet as well as Dr. Mandal also accepts that in its affidavit.
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14. Without any document on the record, we cannot say whether any preventive measures were taken during the treatment of the patient, therefore, in the absence of appropriate evidence from the side of Ops it cannot be said that sufficient preventing measures were taken to check nosocomial infections in the hospital. To that extent Op hospital is deficient in its services.
15. In view of the above, we partly accept the complaint with the direction to Op Nos. 1 & 2 to pay a lumpsum compensation for a sum of Rs. 5,00,000/- for deficiency in service, harassment, litigation expenses and for not taking appropriate measures to prevent nosocomial infection as a result of which the stay of the patient was extended and the patient had to be taken from this hospital and was admitted in PGI, Chandigarh, which was able to check these type of infections and patient had once fully recovered from these type of infections. Ops No. 1 & 2 be directed to comply with the above directions within 45 days from the receipt of copy of the order, failing which it shall carry interest @ 9% from the date of order till payment.
16. The arguments in this consumer complaint were heard on 18.12.2015 and the order was reserved. Now the order be communicated to the parties as per rules.
17. The consumer complaint could not be decided within the statutory period due to heavy pendency of Court cases.
(Gurcharan Singh Saran)
Presiding Judicial Member
January 6, 2016. (Surinder Pal Kaur)
as Member
Consumer Complaint No. 42 of 2010 25