National Consumer Disputes Redressal
Dr. Adwait Patil & 2 Ors. vs Priya Shamrao Deshmukh & Anr. on 7 April, 2016
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI FIRST APPEAL NO. 841 OF 2015 (Against the Order dated 04/09/2015 in Complaint No. 190/2011 of the State Commission Maharastra) 1. DR. ADWAIT PATIL & 2 ORS. CONSULTANT AT SHUSHRUSHA CITIZEN'S, CO-OPERATIVE HOSPITAL, 698-B, RANADE ROAD, DADAR WEST, MUMBAI-400028 2. DR. PRAJAKTA PAWAR COUNSULTANT AT SUSHRUSHA CITIZENS, CO-OPERATIVE HOSPITAL, 698-B, RANADE ROAD, DADAR WEST, MUMBAI-400028 MAHARASHTRA 3. SHUSHRUSHA CITIZEN'S CO-OPERATIVE HOSPITAL, 698-B, RANADE ROAD, DADAR WEST, MUMBAI-400028 MAHARASHTRA ...........Appellant(s) Versus 1. PRIYA SHAMRAO DESHMUKH & ANR. R/AT: FLAT NO. 1, SADHANA, 11/H, RANADE ROAD, SHIVAJI PARK, DADAR (WEST), MUMBAI-400028 MAHARASHTRA 2. DR. D.S. MISHRA OFFICE AT-GANESH CLINIC, GANESH BHUVAN, KHED GULLY, OFF. GOKHALE ROAD SOUTH, DADAR WEST, MUMBAI-400028 MAHARASHTRA ...........Respondent(s)
BEFORE: HON'BLE MR. JUSTICE J.M. MALIK, PRESIDING MEMBER HON'BLE DR. S.M. KANTIKAR, MEMBER For the Appellant : Dr. (Mr.) M. S. Kamath, Auth. Rep. For the Respondent : For the Respondent No. 1 : Mr. Shreeram Shirsat, Advocate For the Respondent No. 2 : In Person Dated : 07 Apr 2016 ORDER DR. S. M. KANTIKAR, MEMBER
1. The complainant, Ms. Priya Shamrao Deshmukh, (in short, referred as patient), was suffering from Cough and Cold. On 15.9.2008, Dr. D. S. Mishra (OP-1) examined her and prescribed tablet Gatri 400 (gatifloxacin). After consuming the said tablet, the complainant developed high grade fever on the same day and noticed rashes and blisters on her skin with deep itching sensation and uneasiness. As per advise of OP 1, she consulted OP 2, Dr. Adwait Patil on 16.9.2008 at Shushrusha Citizen's Co-operative Hospital(OP4) (in short, Shushrusha Hospital). OP 2 diagnosed it as a chicken pox and admitted her in the Hospital (OP 4). However, the rashes and boils aggravated. Dr. Prajakta Pawar (OP-3) a Dermatologist of same hospital examined the patient and opined that, it was due to allergy from the Gatifloxacin prescribed by OP 1. She was in the hospital from 16.9.2008 to 23.9.2008, OP 3 went on experimenting on her, patient developed blisters all over the body but there was no improvement. Further, her condition continued to deteriorate, she was unable to swallow the food. She was kept on liquid diet. On 22.9.2008, the patient was shifted to ICU for TEN. The patient was allergic to Crocin also, but due to advice of physician Dr. Soman from Hinduja Hospital, the OP 2 continued to administer doses of Crocin, which further worsened patient's condition. Therefore, not satisfied with the treatment of OP1, the patient sought discharge with DAMA (Discharge against medical advice on 23.09.2008) and got admitted herself in Saifee Hospital. She was treated Saifee Hospital under ICU care till 31.10.2008. The complainant alleged that, due to wrong treatment and negligence of the OP 2 and 3, she suffered permanent loss of eye lids, partial loss of eye sight and permanent loss of tear glands eyes along with financial loss, mental agony. Therefore, the complainant filed the complaint before the State Commission, Maharashtra for total compensation of Rs.35 lakhs from opposite parties 1 to 4.
2. The State Commission partly allowed the complaint and awarded total compensation of Rs. 20 lakhs (Rs. 5 lacs each from OP 1 to 4) along with total costs of Rs.25,000/- to be shared by all the opposite parties.
3. Aggrieved by the impugned order, OP 2/ Appellant Dr. Adwait Patil filed this first appeal. The OPs 2, 3 and 4 are represented by Dr. M. S. Kamat, an authorized representative. During argument, OP 1/Dr. D. S. Mishra, was also present in person. He submitted that he had already complied with the order of State Commission and paid proportionate amount of compensation.(Rs5 lacs) to the complainant, as compliance to the order of State Commission. Therefore, he should be parted away from this litigation.
4. The authorized representative Dr.Kamat vehemently argued that the patient was kept under close observation. It is not necessary that, such patient of SJS should be admitted to the ICU immediately. He further stated that the patient took syrup crocin on her own, without any instructions from the doctors at OP 4/Hospital. He further brought our attention to the progress sheet which consists of day to day observation and treatment in the Sushruta Hospital.
5. The rival arguments on behalf of the complainant were that patient was diagnosed as SJS, she was deliberately admitted in the ward having less facilities. The SJS patient should be treated under ICU care, which the OP failed to provide at the initial stage, therefore, the patient's condition deteriorated and subsequent complications of SJS arose. Learned counsel brought our attention to various medical literatures on management of SJS and TEN.
6. The authorized representative Dr.Kamat explained the chronological details of patient's course in hospital from 16 - 22.09.2008 as follows;
Dr. Adwait Patil (OP-1) admitted the patient in OP-3, he diagnosed the patient as having febrile illness (fever) + acute severe allergic skin reaction known as Steven Johnson's Syndrome probably due to reaction to drug or due to infection (fever). She was never diagnosed as chicken pox. Thereafter, the patient was referred to Dr. Prajakta Pawar, Consultant Dermatologist (Skin Specialist) for SJ Syndrome and later on both doctors jointly managed the case till her stay in our Hospital. Both Dr. Patil and Dr. Prajakta Pawar took maximum care of the patient who was treated with antibiotics, antipyretic and steroids for her fever and SJ Syndrome. The doctors also referred this patient to Dr. Rajeev Soman, a senior physician, who had examined her, agreed with their diagnosis and treatment, and continued the same line of treatment. The patient was also referred to Dr. R. H. Maniar, Consultant Ophthalmologist for her ocular complainants and eye lid involvement due to SJS.
He further submitted that, Steven Johnson Syndrome is a very serious allergic skin condition which progressed in this patient to Toxic Epidermal Necrolysis (TEN) and it is usually life threatening condition where mortality (death) is not uncommon. The hospital and its doctors had repeatedly and regularly explained the serious condition of patient to her relatives and that's why she was shifted to Intensive Care Unit of the hospital on 22.9.2008.
7. We have perused the medical record of OP-4 hospital. It is clearly shows that, at the time of admission, patient had itching, rashes on the upper abdomen and difficulty in swallowing. Dr. Adwait Patil, OP 1 provisionally diagnosed the patient as PUO (Pyrexia of unknown origin), ? drug reaction ? Steven Johnson Syndrome. On admission, patient was administered antibiotic- Monocef, Inj. Omaz, and Tab. Calpol. Patient was seen by Dr. Pawar and clinically noted that,there was swelling on the eyes and high grade fever of 104° F. Patient showed puffiness of face, swollen eyes, watery discharge, Oral cavity - chapping, ulceration. There was target lesion, trunk palm noted. The patient was treated with dilute H2O2 thrice a day. Advised to wash eyes with saline, also to do oral gargle with dilute KMnO4 (Condy's Gargle) thrice a day. Patient was also given smaller doses of steroids inj. Dexa 8 mg and antihistaminic inj Avil and also advised Betadine Ointment. Further,OP-1 advised investigations for Dengue, Malaria, Widal, Blood culture, urine culture and skin biopsy. On 17.9.2008, patient had pain in throat and difficulty in swallowing, there was no new lesion. The patient was regularly followed by Dr. Pawar. On 18.9.2008, the patient had complaints of redness of eyes but no new lesion; blisters were present on the trunk and chest, fever present. The patient's urinary ketone bodies test was positive and there was albuminuria. On 19.9.2008, the burning on chest, abdomen and back increased, mouth ulcers increased. On that day, there was development of new lesions on Soles, Blister ++. It was advised not to give any antibiotics as there was no temperature. It was also advised Syrup Crocin SOS if temp > 100° F. The patient was examined by Dr. Maniar on 19.9.2008 for the ocular examination. It was found that lid and lashes were normal. There was minimal congestion, hence eye drops were advised in between 2-4 p.m. It is contended that, on 20.9.2008, the patient has taken Crocin Syrup on her own without informing any doctor at 11.00 a.m. Dr. Maniar examined the patient on 20.9.2008 and noted congestion, and eye lid was in same position and called up for follow up on Monday. On the 21.9.2008, Dr. Pawar noticed new lesions again developed, erosions + eyelid + tip of the nose, soles - Erythematous spots ++ and it was suspected that patient may be reacting to Paracetamol. The patient had 103 ° F temperature. Dr. Pawar advised inj. Azee 1 gm, IV BD and paracetamol. Counsel for patient contended that despite suspecting reaction, again Paracetamol was advised. Subsequently, the patient had difficulty in deglutition. Thereafter, Dr. Pawar on 22.9.2008 noted erosions of the upper eyelid, lower eyelid, therefore suspected that the patient was going into Toxic Endodermal Necrosis (TEN). They were unable to explain the cause of fever. Dr. Pawar again asked to refer Dr. Adwait Patil for cause of fever. Thereafter, as per the advice of Dr. Pawar, the patient was advised to shift to ICCU. Dr. Rajiv Soman, senior physician was called. He also diagnosed TEN and advised to continue steroids, anti-histaminics, IV fluids and SOS Cyclosporine. He withheld the inj. Azee. Dr. Maniar, Ophthlmologist also examined the patient on 22.9.2008. It was noticed that lesions falling of rest are normal. The patient was advised to put the RT but it was not possible. On 22.9.2008, maximum liquids, gargle, eye care was advised KMNO4 and saline wash was advised. Also, it was advised to ask Dr. Soman about giving IV antibiotics as a daily review. On 23.9.2008, the patient was examined by Dr. Aruna, who also noted the same findings.
8. Both the parties filed medical literature from Golwalla Medicine for students, Goodman & Gilman's, the Pharmacological basis of Therapeutics, Harrison's internal medicine , Essentials of Medical Pharmacology, and Textbook of Dermatology, The current understanding of Stevens-Johnson syndrome and toxic epidermal necrolysis. Counsel for the complainant referred the literature on management of SJS. A disease severity scoring system called SCORTEN (Score of TEN) has been established to help physicians assess the severity of illness in people with SJS and TEN. This scoring system includes seven distinct factors: age; malignancy; percentage of body surface area detached; heart rate, serum urea; serum glucose; and serum bicarbonate levels. For each prognostic factor that is present in an affected individual, one point is scored. The more points a patient has, the higher is the risk of fatality. One point is given for each of seven criteria present at the time of admission. The seven criteria are:
º Age > 40 º Presence of malignancy.
º Heart rate > 120 beats per minute º Initial percentage of epidermal detachment > 10% º Serum bicarbonate < 20 mmol/l º Serum urea > 10 mmol/L º Serum glucose > 14 mmol/L Patients with a SCORTEN score of > 3 should be managed in intensive care.
9. The diagnosis of SJS is based upon identification of characteristic symptoms, a detailed patient history, a thorough clinical evaluation and a skin biopsy. The appearance of the lesions and their rapid progression may enable a physician to make a diagnosis of SJS or TEN. In all cases, a skin biopsy, in which a tiny piece of affected skin is removed and studied under a microscope, should be performed. A biopsy can reveal the layer of skin blistering (sub epidermal in SJS/TEN) and dead (necrotic), thickened epithelial tissue, which is indicative of SJS and TEN.
10. Management of patients with Stevens-Johnson syndrome is usually provided in intensive care units or burn centers. No specific treatment of Stevens-Johnson syndrome is noted; therefore, most patients are treated symptomatically. In principle, the symptomatic treatment of patients with Stevens-Johnson syndrome does not differ from the treatment of patients with extensive burns. Patients should be treated with special attention to airway and hemodynamic stability, fluid status, wound/burn care, and pain control. Care in the emergency department must be directed to fluid replacement and electrolyte correction. Treatment is primarily supportive and symptomatic. Some have advocated corticosteroids, cyclophosphamide, plasmapheresis, hemodialysis, and immunoglobulin.
11. It is pertinent to note that the instant case pertains to a patient of 23 years young lady, a Homeopath doctor. Due to fever and drug reaction, the OP-1 diagnosed it as ?PUO/SJN. Considering the history and signs of allergic reaction, the OP should have been more vigilant. Patient was investigated for Dengue, Malaria also. The diagnosis of SJS, which will become fatal if not monitored closely. Fever could not come down for 6 days, the OPs were unable to diagnose the causes of fever. The SJS is like a burns injury, such patients should be handled with care and kid gloves. In the instant case the hospital record is devoid of SCORTEN assessment. In addition, the patient showed signs of increase in new lesions. It was suspected to be merging into overlap stage of epidermal necrolysis and hence was transferred on 6th day to ICU for further monitoring.
12. Intensive care units (ICUs) are specialist hospital wards. They provide intensive care (treatment and monitoring) for patients in a critically ill or unstable condition. A person in an ICU needs constant medical attention and support to keep their body functioning. Stevens-Johnson syndrome is a medical emergency that usually requires hospitalization. Treatment focuses on eliminating the underlying cause, controlling symptoms and minimizing complications. Recovery after Stevens-Johnson syndrome can take weeks to months, depending on the severity of condition.
13. The initial goal of managing suspected SJS/ TEN is to provide essential life support, as both conditions pose a significant risk of dehydration and infection during the acute phase and admission to a burn unit may be necessary. Mortality rates range from 1 to 5 percent for SJS and up to 50 percent for TEN. In the instant case, patient was diagnosed as SJS; patient should have been kept in ICU for continuous monitoring of serious drug reaction. Initially, eye care is often superseded by the life-threatening dermatologic concerns. Eye examination should be an essential component of the evaluation of any patient with suspected SJS/TEN. The most common and devastating long-term complications often are ophthalmic in nature. As these complications can be minimized or even prevented with early intervention.
14. The OP did not produce any evidence to show that, the ICU/ICCU was fully occupied by the patients during 16 to 23.09.2009. Even there is no evidence that, patient herself denied ICU admission. But, the patient was treated in the ward for 6 days, SJS went on deteriorating. Finally, the patient took treatment in Saifee Hospital under ICU care and got cured at some extent, but her ocular damage persisted. Thereafter, she consulted at LV Prasad Eye Institute at Hyderabad on 2.3.2010, wherein she was diagnosed as Madarosis in both eyes and Trichiasis in right eye. She was referred to Boston Scleral Contact lens clinic.
15. As per medical literature, Stevens-Johnson syndrome (SJS) and its more severe variant, toxic epidermal necrolysis (TEN), are inflammatory disorders of the skin and mucous membranes that are characterized by acute, life-threatening blistering and necrosis. These conditions require extensive wound care, pain management, fluid and nutrition resuscitation, and respiratory support.
16. In this context, we would like to rely upon the judgment in Laxman Balkrishna Joshi (Dr.) Vs. Dr. Triambak Bapu Godbole, AIR 1969 SC 128, it was held that a doctor when consulted by a patient owes him certain duties. It has held as under:
A person, who holds himself out ready to give medical advice and treatment, impliedly undertakes that he is possessed of skill and knowledge for the Purpose. Such a person when consulted by a patient owes certain duties, namely, a duty of care in deciding whether to undertake the case, a duty of care in deciding what treatment to give, and a duty of care in the administration of that treatment.
17. In the instant case, the patient of SJS, who was deteriorating day by day, was treated in general ward for 6 days. Proper ICU care and monitoring could have prevented damage to the patient's eyes like Madarosis and Trichiasis. No doubt, OP-2 and 3 treated the patient, but it was delayed decision to shift the patient to ICU. SJS and TEN are clinically similar except for their distribution. By one commonly accepted definition, changes affect < 10% of body surface area in SJS and > 30% of body surface area in TEN; involvement of 15 to 30% of body surface area is considered SJS/TEN overlap. Treatment is most successful when SJS or TEN is recognized early and treated in an inpatient dermatologic or ICU setting; treatment in a burn unit may be needed for severe disease. Ophthalmology consultation and specialized eye care are mandatory for patients with ocular involvement.
18. The definition of 'medical negligence' is when a medical professional with a duty to provide care fails to do so, resulting in harm to the patient. As such, as a common form of medical negligence, delayed treatment cannot be excused. In our view, OP-2 and 3 have failed in their duty of care to some extent. It is settled law that hospital is vicariously liable for the acts of the doctor vide Savita Garg Vs. National Heart Institute , (2004) 8 SSC 56, it was also followed in case of Balram Prasad v. Kunal Saha , (2014) 1 SCC 384 . Therefore, the hospital OP-4 is vicariously liable.
19. Adverting to the quantum of compensation, the award of State Commission appears to be on the higher side. The complainant had already received Rs. 5 lacs from Dr.D. S. Mishra towards compensation. Therefore, considering the sufferings of the complainant and facts of case, the additional sum of Rs.5 lacs will be just and proper compensation in this case.
20. Therefore, we modify the order of State Commission and direct the Shushruta Hospital (OP-4) to pay Rs. 5 lacs to the complainant, within four weeks from the date of receipt of this order, failing which, the said amount shall carry interest @ 9% per annum from the date of this order, till its realization. However, there shall be no order as to costs.
......................J J.M. MALIK PRESIDING MEMBER ...................... DR. S.M. KANTIKAR MEMBER