National Consumer Disputes Redressal
Nazreth Hospital & 2 Ors. vs Sona Singh on 12 July, 2016
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI FIRST APPEAL NO. 608 OF 2015 (Against the Order dated 26/06/2015 in Complaint No. 109/2012 of the State Commission Uttar Pradesh) 1. NAZRETH HOSPITAL & 2 ORS. THROUGH ITS DIRECTOR, 13-A, KAMLA NEHRU ROAD, ALLAHABAD 2. NAZRETH HOSPITAL, THROUGH CONTROLLER, 13-A, KAMLA NEHRU ROAD, ALLAHABAD 3. DR. CYNTHIA TIMOTHY, SURGEON/CONCERNED DOCTOR, NAZRETH HOSPITAL, 13-A, KAMLA NEHRU ROAD, ALLAHABAD ...........Appellant(s) Versus 1. SONA SINGH W/O. SHRI TEJ PRATAP SINGH, R/O. 1/3-F DAYANAND MARG, NEAR RADIO STATION, ALLAHABAD CITY DISTRICT ALLAHABAD ...........Respondent(s)
BEFORE: HON'BLE MR. JUSTICE J.M. MALIK, PRESIDING MEMBER HON'BLE DR. S.M. KANTIKAR, MEMBER For the Appellant : Mr. Vikas Vikram Singh, Advocate For the Respondent : Mr. R.P. Mishra, Advocate Dated : 12 Jul 2016 ORDER DR. S.M. KANTIKAR, MEMBER This order shall decide both the above detailed appeals, the facts are drawn from FA No. 590 of 2015. For the convenience, the parties are placed in the same position as mentioned in the complaint.
1. The complainant Smt. Sona Singh ( here-in-after referred as "the patient") underwent hysterectomy operation (removal of uterus) on 15.11.2011 in Nazrath Hospital(OP-1). It was performed by Dr. Cynthia Timothy (OP3). After operation, the patient apprehended and intimated the doctor that both of her kidneys got damaged. Therefore, the OP-1 hospital forcibly discharged her on 19.11.2011 and referred to SGPGI Hospital, Lucknow. She was treated at SGPGI and discharged on 09.12.2011 without any cure. The doctors at PGI diagnosed and informed the patient that her both kidneys got damaged due to Acute Tubular Necrosis(ATN) because of gross negligence of doctors at Nazrath Hospital. Therefore, only option left for the complainant was to get done renal transplantation. Thereafter, till date, the patient is on medicines and taking regular dialysis, twice a week. Therefore, she has to incur expenses to the tune of Rs. 15,000/- per month. Thus, it is alleged that, due to negligence of the doctors at OP-1 hospital, her life became miserable. She has been deprived of love and affection of her husband and two sons. Therefore, the complainant filed Consumer complaint before the State Consumer Disputes Redressal Commission,Luknow,UP (in short "the State Commission") and prayed for Rs. 85 Lakh as compensation.
2. The State Commission allowed the complaint and directed the OPs to pay Rs. 35 Lakhs along with 9% interest from the date of filing of the complaint + Rs. 15,000/- as litigation charges. Therefore, aggrieved by the said order, the complainant Sona Singh filed FA 590/ 2015 for enhancement of the compensation whereas, FA 608/ 2015 filed by the OPs for dismissal of complaint. .
3. We have heard the learned counsel for both the parties. The counsel for the complainant vehemently argued that, there was gross negligence during the treatment of the patient. At the time of hysterectomy operation, there was more bleeding, by which the patient's kidneys got damaged. The OP-3 concealed the said damage and referred the patient to SGPGI, Lucknow. The counsel relied upon the expert opinion given by Dr. S.P.Narayan. Also brought our attention to the discharge summary issued by the SGPGI which has mentioned that patient suffered kidney damage.
4. The counsel for OPs vehemently argued that, OP-3 along with team of doctors performed operation successfully; there was no complication or negligence in conducting operation. The post-operative care was proper, but unfortunately patient suffered post operative sepsis/acute renal failure with hyponatremia and hypokalemia. Same was treated immediately as per standard protocol. The patient developed ATN because of infection. The counsel placed further reliance upon medical literature from the international medical journals. As per literature titled "An Overview of Hysterectomy", 2008:33(9):HS11-HS20.
Infection is a common postoperative complication associated with hysterectomy. Four percent to 10% of patients undergoing vaginal hysterectomy and 6% to 25% of those having abdominal hysterectomy develop an infection post surgery. In all, regardless of the careful precautions taken, approximately one-third of patients develop postoperative febrile infection. Because of this, the use of preoperative and postoperative interventions, such as prophylactic treatment with broad-spectrum antibiotics, can contribute greatly to the reduction of infections occurring with hysterectomies.
While the aforementioned complications are more common, the following complications, although rare, also can occur atelectasis, fallopian tube prolapse, thromboembolic disease, myocardial infarction, stroke and renal failure.
5. The counsel for OPs vehemently objected that, Dr.Narayan is not a competent expert to opine, because his qualification is M.B.B.S DLO PMHS, he has retired from health service. The medical record does not mention that, on 19.11.2011, there was forcible discharge of the patient from the hospital, on the account of damaged kidneys. In fact she was referred to SGPGI on the insistence of her relatives. Even the complainant has not impleaded SGPGI in this case. Therefore, the complaint should be dismissed for non joinder of the parties. The counsel further relied upon the Judgment of Hon'ble Supreme Court in Vineeta Ashok Vs. Laxmi Hospital 2001 (A) SSC 731 and Jacob Mathews Case (2005) 6 SCC 1. The counsel further contended that simply because the patient has not responded favourably to a treatment given by physician or surgeon, he cannot be held responsible and the doctrine res ipsa loquitor is not applicable in the instant case.
6. The OP relied upon few medical research articles from international journals (Annexure No. 3). The infection is a common post operative complication associated with hysterectomy regardless of the careful precautions taken, approximately one third (1/3rd) of the patients develop post operative febrile infection. Apart from common complications the following complication, although rare, also can occur atelectasis, fallopian tube prolapse, thromboembolic disease, myocardial infraction, stroke and renal failure.
7. The counsel for OP further contended that the complainant was suffering from irregular and excessive PV bleeding i.e. menorrhagia, since 2009. She was treated by excessive oral contraceptive. As per research article BMJ Case reports 2013 "Oral Contraceptive causing renal artery thrombosis", the oral contraceptives lead to renal artery thrombosis. Clinicians should regard renal vein thrombosis as one of the differential diagnoses for acute flank pain in patients using oral contraceptives.
8. We have perused the medical record from Nazrath Hospital, Srijan Hospital and the SGPGI. Also perused the three expert medical opinions on record. Dr. Narayan gave his opinion (Annexure 11) on behalf of patient, whereas the OPs placed two opinions, one from their own expert committee ( Annexure-CA3) and another opinion from SGPGI, Luknow(Annexure-8).
9. Dr. Narayan, a retired joint director from Medical and Health Department, opined that, there was no indication of oophorectomy (removal of ovary) in this patient at the age of 39 years. It caused shock and aggravated the hypothyroid state in the patient. It might have caused renal cortical necrosis (acute tubular necrosis -ATN). Because of hospital negligence, the patient developed septicaemia on 19.11.2011. The BHT also showed bleeding+, therefore at that stage OP, should have opened the abdomen to stop the bleeding. The continuous bleeding from the operated site caused oligemia (hypovolemia), leading to acute renal cortical necrosis. He also opined that, OP delayed the decision to use Corticosteroid i.e. injection Efcorlin, otherwise it would have changed the premise in this case.
10. The opinion of experts at Nazrath Hospital, (OP-1) is reproduced as follows ( Annexure CA-3) "DETAILED TREATMENT SUMMARY Case summary of the patient Smt. Sona Singh, W/o Tej Prataph Singh, Aged about 39 years, Sex: Female, OPD No. 55036/2011, IPD No. 11730/2011 R/o 1, Dayanand Marg, Near Radio Station, Allahabad.
The aforesaid patient was under my treatment for approx. 1 ½ years for irregular periods, Menorrhagia and p/v discharge and Inter-menstrual bleeding, but could not be relieved after treatment and patient advised for Hysterectomy Operation.
She was admitted to Nazareth Hospital, Allahabad as a case of Fibroid Uterus with chronic cervicitis with Hypothyroidism on 14th November 2011 for operation. She underwent Abdominal Hysterectomy with bilateral salphingo oophorectomy operation on 15th November 2011. Patient was absolutely fine for three days after the operation. Her vitals were normal. However her urine output declined on 18th November 2011. Immediate measures were taken by Physician (Dr. G.S. Sinha, MD) and the patient immediately referred to Nephrologist Dr. Anurag Singh, MD, DM (Nephro.) of this Hospital for further evaluation and management. On evaluation evidence of sepsis with ARF was found; so she was transferred under care of Dr. Anurag Singh for further management at our hospital. She was given 1 session of dialysis along with change in antibiotics. However in view of patient relative's insistence she was referred to SGPGI, Lucknow.
There was no negligence in operation and post-operative treatment by the doctors concerned and the Hospital.
Dr. Cynthis Timothy, MS Rev. Fr. K.K. Antony Dr. G.S. Sinha, MD Dr. Anurag Singh, MD, DM (Gynae. & Obst.) Director Consultant Physician Nephrologist
11. Further, we have perused the Expert Committee's opinion from SGPGI, Lucknow at page 103 of FA No. 608 of 2015, it is reproduced as follows:
Mrs. Sona Singh, 39 years, female, presented to emergency of SGPGI at 1.20 a.m on 20.11.2011 with complaints of swelling of body for three days, fever for 1 day and decreased urine output for three days. As per history and documents available with the patient, she underwent hysterectomy on 15.11.2011 at a private hospital in Allahabad. She became anuric in post-operative period and was given 1 session of Hemodialysis on 19.11.2011 and was subsequently referred to this Hospital. She was admitted to Nephrology HDU at 1.34 am on 20.11.2011. On examination patient has poor general status, dyspnea, and evidence of chest infection. On investigation Hb 10.2, TLC 49.5, Platelet count 37000, S. Creat 4.1, Na 139, K+ 4.8.
In view of the advanced renal failure and oliguria, dialysis was given on alternate days such as 20.11.2011, 22.11.2011, 25.11.2011, 27.11.2011 (with 2 unit of blood and 2 units of plasma). Right IJV catheter was inserted on 28.11.2011. Patient was made stable and in view of persistent oliguria, renal biopsy was done on 30.11.2011. Histopathology of biopsy revealed acute cortical necrosis which is usually irreversible or partial reversible. Patient remained dialysis dependent hence AVF was made on 6.12.2011. She was discharged with advise for twice per week dialysis at local centers, medications, and monitoring of s. creatinine and urine output.
12. After perusal of entire record, expert opinions and our thoughtful consideration, the main issue which swirls around is, "whether there was deficiency or negligence during TAH operation or during post-operative care causing damage to both kidneys (ATN) of patient?".
13. It is true that, the OP-3 is a qualified Surgeon. As per pre operative laboratory and radiological investigations, patient's kidneys were normal. After TAH, patient developed complications and was referred to SGPGI on the insistence of her relatives. As per the counsel for OPs, on the receipt of legal notice from the complainant, the OP hospital had set an enquiry panel of three senior doctors( Gynecologist, Physician and Nephrologist) of the same hospital. The said committee after deliberation and going through medical record, case history opined that there was no negligence during operation and post-operative care by the doctors and hospital management. (Annexure No. 7).
14. It is surprising that, the enquiry panel consists of doctors who themselves are alleged for medical negligence in this case. The said joint report was contradicted by Dr. S.P. Narayan. As per Dr. Anurag Singh's clinical notes/report, the patient started having increased amount of urine then subsequently on 17.11.2011 there was complete absence of urine, also serum creatinine and blood urea values were raised on 18.11.2011. The patient developed anuria and septicaemia, therefore OP hospital referred the patient to SGPGI. The opinion from experts at SGPGI clearly mention that patient was admitted in emergency condition; patient had swelling over body, decreased urine output for 3 days, and one day fever. Patient was already in advance stage of renal failure.
15. In this context, we have perused the Text book of Shaw's Gynaecology and some literature to know about post operative Acute Renal Failure (PO-ARF). It is known that, ureteric injury is a rare, but severe complication of pelvic surgery which is recognised post operatively. If such injury is not recognized immediately, it may lead to anuria, fluid overload, renal failure and even death. The injury can either be caused by a ligation, trans-section, crushing, tethering or an excision of a portion of the ureter. For the surgeon who is trying to do his best for the patient, this injury can deal a devastating blow to his or her morale. It is therefore incumbent on all practitioners performing procedures around the ureter to be aware of the spectrum of possible injuries to the ureter, factors that increase the risk of injury and techniques for early recognition. Such knowledge will minimize the risk of inadvertent injury and if they occur allow expeditious recognition and referral to appropriate centres to facilitate their repair. For these reasons, injuries to the urinary tract, particularly the ureter, are the most common cause for legal action against gynecologic surgeons.
16. Nevertheless, when a ureteral injury does occur, quick recognition of the problem and a working knowledge of its location and treatment are essential in providing patients with optimal medical care. Therefore, Postoperative ARF (PO -ARF) should be looked at as a "preventable" rather than "treatable" clinical entity. Postoperative mild renal dysfunction can be treated by early management of renal hypovolemia, but prolonged renal hypovolemia may induce renal parenchymal damage such as renal tubular necrosis. It means early diagnosis and early management are more important than continuous treatment. Preoperative and postoperative intravascular blood volume has a great impact on development of PO-ARF, and massive intra-operative bleeding or hypotension frequently cause PO-ARF.
17. It is very difficult to recover from renal function after development of postoperative ARF. It is therefore necessary to monitor these patients with postoperative renal function and urine output. If a postoperative oliguric state is detected, aggressive volume expansion should be started immediately, with or without furosemide(Lasix) , followed by haemodialysis. A significant finding was that symptoms suggestive of bilateral injury (oliguria and anuria) were present in the early post operative period. However, because there was excessive intra-operative bleeding, the low urine output was misdiagnosed as prerenal acute renal failure in some cases. This resulted in a delay of several days as the kidneys were challenged with fluids and furosemide.
18. Surgical operations adjacent to the ureters may occasionally result in bilateral ureteric injury, hence due caution must be taken during control of bleeding .The surgeon must be vigilant in the immediate post-operative period. Oliguria or anuria following pelvic surgery should be assumed to be as a result of bilateral ureteric injury until proven otherwise. Such patients should be promptly referred for urological evaluation because delay in diagnosis is the most important factor contributing to the morbidity and rarely mortality of bilateral ureteric injury.
19. In the instant case, the medical record from Nazrath Hospital is devoid of exact post operative scenario of the patient for 48 to 72 hours. The BHT revealed bleeding +. The progress notes show one unit of blood transfusion, and Blood Pressure. It is pertinent to note that the Nurse's record dated 17.11.2011 is conspicuously missing. Nothing is mentioned about fever or infection. Thus , in absence of proper medical record in the instant case, the cause of bilateral renal damage should be either due to ureteric injury or intra-operative bleeding.
20. It's very important that, the treating doctor should properly document the management of a patient under his care. Medical record keeping has evolved into a science of itself. This will be the only way for the doctor to prove that the treatment was carried out properly. It is wise to remember that "Poor records mean poor defense, no records mean no defense". Medical record includes a variety of documentation like patient's history, clinical findings, diagnostic test results, surgical procedure, preoperative and postoperative findings.
21. Therefore, in our view, the complainant discharged her initial burden to prove negligence on the hospital/OPs. In this context, we rely upon the landmark judgment of Hon'ble Supreme Court in Savita Garg Vs. National Heart Institute , (2004) 8 SSC 56, wherein it is stated as follows:
"when a prima facie case is established, it is the duty of the opposite parties to prove their case, since it is only the opposite parties who are aware of the exact line of treatment that has been given to the patient. It was also held by the Apex Court that once a claim petition is filed and the complainant has successfully discharged the initial burden that the hospital/clinic/doctor was negligent and that as a result of such negligence, the patient died, then in that case, the burden lies on the hospital and the doctor concerned, who treated the patient, to show that there was no negligence involved in the treatment."
22. Thus, on the basis of foregoing discussion, it is clear that the patient suffered bilateral renal damage due to negligence in the treatment of the patient. The OP failed to explain why there was post operative acute renal failure. The State Commission awarded a compensation of Rs. 35 lakhs. The complainant preferred an appeal for enhancement of compensation. It is true that the patient is on regular dialysis and regular medical treatment from SGPGI, MS, Lucknow. It is also imminent that the patient needs renal transplant because she is a young lady of 39 years and cannot sustain dialysis, twice a week, throughout her life.
23. In our view, the patient is taking dialysis for the last six years and might be incurring heavy expenditure. Even after kidney transplant, she needs regular medical supervision and treatment. Therefore, considering the facts and circumstances of the case, we are of the considered view that the compensation awarded by the State Commission, is just and reasonable. There is no need for enhancement. Therefore, on the entirety of the facts, we dismiss both the appeals.
......................J J.M. MALIK PRESIDING MEMBER ...................... DR. S.M. KANTIKAR MEMBER