National Consumer Disputes Redressal
K. Ravindra Nath (Dr.) And Anr. vs Vitta Veera Surya Prakasam And Ors. on 17 August, 2006
Equivalent citations: IV(2006)CPJ105(NC)
ORDER
P.D. Shenoy, Member
1. This is a case of alleged medical negligence where a gastroenterologist performed explorative Laparotomy in a suspected case of Teratoma to remove the big lump from the abdomen along with one of the ovaries and left a surgical mop in the abdominal cavity which resulted in complications which necessitated a second surgery by a surgical oncologist.
Case of the complainant:
2. Complainant No. 3 - Ms. Vitta Sireesha is a 13 years old daughter of Shri Vitta Veera Surya Prakasam. In the second week of March, 1997 she complained of stomach disorder, pain in leg and vomiting sensation. Local doctor at Kurnool advised the patient to take her to Apollo Hospital, Hyderabad. After conducting various tests, Dr Ravindra Nath, Gastroenterologist diagnosed the disease as Immature Teratoma and advised immediate surgery on 20.3.1997 and the patient was discharged on 27.3.1997. The patient was advised to have Chemotherapy at the time of discharge. On 9.4.1997 at about 4.00 p.m. as pus to the tune of 150 to 200 ml oozed out from the sutures, the patient was immediately rushed to Hyderabad. They reached the hospital at 4.00 a.m. on 10.4.1997 and though the operating surgeon was informed, he did not come out for a full day. Only the duty doctor at casualty came at 7.00 p.m. and dressed up the wound. On 11.4.1997 Dr Nath examined the patient with naked eye and told the patient that there is no need to worry and prescribed some medicines. This exercise was repeated on 22.4.1997 and 31.3.1997. As advised by Dr. R. V. Rao the patient was taken to M N J Hospital on 20.5.1997 where Dr. Rao examined her and diagnosed the disease as 'Immature Teratoma' Stage III C Cancer and stated that there is no hope of survival of the patient. But the father of the patient took her to Nizam Institute of Medical Sciences (hereinafter be referred as NIMS) Hyderabad for a second opinion on 23.5.1997, where it was noticed that some foreign body was left at the time of surgery besides certain intestines were perforated and second surgery was done on 30.6.1997 and the patient was discharged. The complainant alleged that doctors at the Apollo Hospital have committed gross negligence and dereliction of their duties and claimed Rs. 10 lakh as compensation for the injuries, towards mental agony, pain; expenses suffered by the complainants.
Case of the opposite parties:
3. The Managing Director, Hyderabad Apollo Hospitals, Dr. K. Ravindranath, Gastroenterologist and Dr. R. V. Rao, Oncologist at the same hospital were the opposite parties before the State Commission. On clinical examination of the patient, the patient was found to be anemic and her abdomen had huge mass occupying almost the whole abdomen. She was diagnosed to be suffering from Immature Teratoma Right Ovary with secondaries and surgery was planned. Blood transfusion was given. Laparotomy was done under general anaesthesia on 20.3.1998 which revealed the following:
(a) right ovarian tumour of variable consistency
(b) ascites
(c) deposits in vesico-uterine pouch and pouch of Douglas (2 in No. 2 x 2cm x 1 x 2cm)
(d) Omental secondaries (3x3 cm)
(e) Small multiple deposits in pelvis
(f) Small deposits in opposite ovary.
Sutures were removed on 29.31997 and wound healed well. In view of the Immature Teratoma with secondaries, the patient was referred to Medical Oncologist who advised chemotherapy. They denied the allegation that no body turned up to enquire about the patient's condition on 10.4.1997, The second surgery conducted at NIMS was superfluous. The patient had an abscess, which drained by itself and was in the process of healing. Formation of abscess after such an extensive surgery is not uncommon. The allegation that there was surgical mop in the abscess after the surgery was baseless. Pathology report on biopsy that foreign body granulomas were present is not uncommon and histological finding is not significant.
4. The State Commission after examining Dr. K. Ravindranath, Dr. Rao and Dr. G. Suryanarayana Raju, Head of the Department of Surgical Oncology, NIMS who performed the second surgery and after going through the voluminous records of the case came to the conclusion that the complainants have established deficiency in service on the part of the opposite party 1 - Apollo Hospital, Hyderabad and opposite party No. 2 Dr. K. Ravindranath who are jointly and severally liable for the damages sustained by the complainant. The State Commission also awarded Rs. 1.00 lakh towards medical expenditure for both the surgeries and for treatment and another Rs. 1.00 lakh towards compensation for mental agony, physical pain to complainants 1 and 2 along with interest @ 12% per annum from the date of filing of the complaint till realization. Complaint against opposite party No. 3-Dr. R.V. Rao was dismissed. Rs. 10,000 were also imposed as costs.
5. Aggrieved and dissatisfied by the order of the State Commission, three appeals have been filed.
1. FA No. 814 of 2003 filed by Dr K Ravindranath.
2. FA No. 284 of 2004 filed by M/s. Apollo Hospital.
6. These two appeals were for setting aside the order of the State Commission and for allowing their appeals. FA No. 308 of 2004 was filed by Vitta Veera Surya Prakasam and others with a request to enhance the compensation amount. As these three appeals were interrelated they were heard together.
Submissions of the learned Counsel for the complainant:
7. learned Counsel for the complainant submitted that-
(a) the second opposite party Dr. Nath claims to be a urgical Gastroenterologist having a fellowship in FRCS Glasgow and Edinborough, UK was not competent to perform the surgery in this case. He invited our attention to the Indian Medical Council Act, 1956. according to which FRCS in Gastroenterology is not recognized.
(b) The second limb of his submission is that the postoperative care was inadequate at Apollo Hospital. The patient was made to wait for more than 24 hours. The patient came to the hospital at 4.00 a.m. by travelling the whole night from her native place. The surgeon never came to see her on that day though she had a gaping wound as a result of surgery and was- suffering from excruciating pain and complications.
(c) There was gross negligence on the part of the hospital as well as Dr. Nath in not performing the surgery properly on 27.3.1997 which resulted in complication that required second corrective surgery at NIMS to rectify the problems created by the first surgery.
8. Lastly he drew our attention to the Chief Examination of Dr. G. Suryanarayana Raju, Head of the Department of Surgical Oncology NIMS where he clearly mentioned as follows:
We found a mass in the pelvis with infection, which was drained and removed. We removed the mass and sent the specimen for Histopathology Examination (Microscopic Examination). The mass was around 15 x 20 centimetres. There was a foreign body. The abscess contained foreign body in the form of surgical mop.
9. Lastly he pleaded that considering the negligence in the first surgery and second corrective surgery and also the prolonged medical treatment of the patient, "the patient was almost in the jaws of death which caused mental worry, agony, annoyance, fear of death, not only in the mind of the patient but also in her parents, grand parents and relatives. Thus the patient Sireesha is a victim of criminal negligence by the doctors at the opposite party hospital. All the family members were subjected to severe mental torture due to the neglected treatment for nearly three months. Due to the Cancer Stage - III (c) Diagnosis little hope was left on patient Sireesha's life. The first complainant lost leave and the patient Sireesha lost her education for three months. Thus the opposite party-hospital is liable to pay compensation of Rs. 20 lakh for the injuries, pain and sufferings and mental torture sustained on account of negligence."
Submissions of the learned Counsel for the Apollo Hospital, Hyderabad:
10. Learned Counsel vehemently argued that no mop was left during the first surgery. The opinion of CW 1-Dr. G. Suryanarayana Raju, HOD of Surgical Oncology, NIMS, is a purely subjective opinion and is contrary to medical records. He submitted that the only document indicating him is the operation record of Dr. Raju which states as under:
15 x 10 cms abscess beneath the anterior abdominal wall, lateral to midline (right) multiple intestinal adhesions with dilated bowels (small) foreign body (surg. sponge) in the abscess cavity left ovary was normal in size with few cysts in the ovary.
Right ovary absent. Uterus normal. Adhesions around it present.
No gross peritoneal deposits. Rest of the viscera was normal.
11. The operation record at page 155 of the paper book wherein it is written 30.6.1997- Laparotomy + Excision of Mass + Repair of Intestinal Perforation + Appendicectomy. He invited our attention to the Histopathological Report which mentions that 'foreign body granuloma'-which does not mean sponge. The surgical sponge is classified as Gossypiboma -the Forgotten Swab.
12. He his submitted that on 21.6.1997 wherein it is stated that at the time of discharge the patient's condition was 'stable'.
13. He also submitted that on 3.7.1997 wherein the NIMS has stated that at the time of discharge the patient is afebrile, sutures removed, wound healthy.
14. The learned Counsel drew our attention to the examination-in-Chief of G.S. Raju. He submitted that there are inconsistencies in his report, though he mentioned that 'we found a mass in the pelvis with infection, which was drained and removed. We removed the mass and sent the specimen for Histopathology examination (Microscopic Examination). The mass was around 15 x 20 centimetres. There was a foreign body. The abscess contained foreign body in the form of surgical mop'. But, he stated in his cross-examination, it is true that we write operation record at the time of surgery. In the Histopathology report dated 3.7.1997, it is true that 4 bits were sent to' microscopic examination and out of 4 bits largest one measuring 4 x 1.5 x 1 centimetre smallest one measuring 15 x 1 x 0.5 centimetre. He has also stated in the cross-examination that 'it is true that it was recorded in the discharge summary, the final diagnosis is POST OP IMMATURE TERATOMA RIGHT OVARY WITH INTRA ABDOMINALABSCESS (Abscess means puss).
15. He quoted their written version which reads as under:
It was unnecessary to take the patient to NIMS as there was no specific problem. It is submitted that the second surgery conducted in the opinion of Senior Consultant in the first Opposite party was unnecessary. The patient had an abscess, which drained by itself and was in the process of healing. Formation of an abscess after such extensive surgery is not uncommon. When it drains by itself that is the best outcome for the patient. The allegation of negligent surgery is totally wrong. On the other hand, a major life saving surgery was performed on the patient successfully. The allegation that it was due to foreign body material is totally baseless. The pathology report on Gopsy that foreign body granulomas were present is not uncommon histological finding. This is a hyper-sensitive reaction of the patient's tissues that occurs in some people. It occurs in such patients as a reaction to the common materials that are used in all surgical procedures like Gloves, Antiseptics and suture material. It has no significance from the point of view of healing or of any complication whatsoever. The allegation that this Histological report of foreign body granulomas means that foreign bodies are left in the patient to the total ignorance of the. complainants.
16. He further submitted that "Abscess can form in cancer patients because their body resistance is very low especially after chemotherapy, and many times lot of sutures were used when doing such a major operation Around the sutures also, infection can form and form abscess around the stitches. It is also called foreign body granuloma. If it is sutures it is not visible. If it is a mop it is 100% visible.' Submissions of the learned Counsel for Dr. R. Nath:
17. Before undergoing the second surgery the patient had gone to NIMS after 45 days of the operation was performed. CT Scan did not show any surgical mop, hence second surgery at NIMS was not necessary. As the teratoma was huge and the operation had to be performed urgently by a surgeon, subsequently cancer was detected and it was referred to an Oncologist for chemotherapy. The learned Counsel further submitted that a surgeon cannot be held responsible if a mop is found in the abdomen after he had performed surgery.
Findings:
18. (1) Medical and surgical records were not given to the complainant. In fact the complainant had to file an interim application before the State Commission to produce the records. The State Commission directed the opposite parties to file the medical records and only after filing the same the complainant came to know that the patient was suffering from 'Immature Teratoma-Right ovary with secondaries-Norris Grade I. The word teratoma is defined as:
A group of tumours, some innocent, other malignant, composed of recognizable tissues {e.g. Fat) and complex organs (e.g. teeth) derived from more than one germinal layer of embryo. Special examples include dermoids and epidermoids. Adult teratoma. A teratoma in which there is considerable differentiation of the component tissues: Autochthonous teratoma. A true dermoid. Congenital teratoma. An epidermoid arising from congenital misplacement of epithelium. Ovarian teratoma. A highly malignant tumour arising. usually in childhood and secreting chorionic gonadatrophin, oestrogen and progesterone. Similar to chorioepithelioma. Polypoid teratoma. A dermoid cyst showing many papillae in its wall. Tridermal teratoma. A teratoma in which derivatives of all three germinal layers of the embryo are represented. (Gk teras monster, -omatumour).
(2) Though the learned Counsel submits that the patient was discharged in stable condition. Stable condition does not mean that he was normal in health. Even a person who is in ICU is referred as 'stable condition'. That the surgery was not perfect is clear from surgical record of NIMS. It is also clear from the records that the patient had come for post-operative care at Apollo Hospital, Hyderabad and for 24 hours she was not seen by the surgeon who performed the operation though, the patient was suffering from writhing pain and complications due to the improper surgery.
(3) The next issue to be decided whether the surgical mop was left in the abdomen while performing the first surgery. This is clear from the surgical record of NIMS wherein Dr. Raju was assisted by Dr. Ashok Malani and Dr. Vasu who conducted the surgery on the patient on 30.6.1997. Further in the examination-in-Chief Dr. G S Raju, CW I, has stated that "we found a mass in the pelvis with infection, which was drained and removed. We removed the mass and sent the specimen for Histopathology examination (microscopic examination). The mass was around 15 x 20 centimetres. There was a foreign body. The abscess contained foreign body in the form of surgical mop." Myself conducted the surgery in the NIMS Hospital. Mass means tissue collection, Tumar, intestine coming together including adjacent organs, uterus and ovaries. While conducting surgery whatever we found in the body we sent to the pathology.
If any mop or foreign body found in the surgery apart from pathology, it will be sent for conducting polarization test to confirm the doubt. Here the interesting point was about the residual tumour and recurrence of ovarian tumour, when we operated we found anapsis with a surgical mop. Then for us still the interesting point was to see any viable tumour associated with abscess.
This witness is the head of the Department of Surgical Oncology who performed the surgery, whose knowledge and competence were not questioned by the opposite parties.
(4) Another issue is that it is the common knowledge if a surgical needle or nife or mop left in the abdominal cavity during the surgery, this can be seen by naked eye and it is not required to be sent for Histopathological test. We do not find any contradiction in the surgical record and examination and the cross-examination of Dr. G.S. Raju, Surgical Oncologist.
(5) One of the issues raised by the learned Counsel for the hospital is that new issues were raised by the complainant before the State Commission which were not averred in the original complaint. This happened purely because the hospital records were not made available to the complainant before the complaint was filed. Records have been filed before the State Commission only after the interim application was filed by the complainant to produce the records. Hence, the complainants could not have seen the medical and surgical records of both the hospitals at the time of filing their complaint.
(6) Accordingly, we do not see that there is a need to interfere with the reasoned order of the State Commission. Hence, appeal Nos. 814 of 2003 and 284 of 2004 are dismissed.
19. Coming to the quantum of compensation in the appeal filed by the complainant, we feel that ends of justice would be met, if a round sum of Rs. 3.5 lakh is awarded as compensation towards medical expenditure, mental agony and trauma faced by the complainant. Order accordingly. There shall be no order as to costs.