National Consumer Disputes Redressal
Smt Anju Sharma And Ors vs Dr D Sinha And Ors on 14 July, 2011
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
NATIONAL CONSUMER
DISPUTES REDRESSAL COMMISSION
NEW
DELHI
FIRST APPEAL No. 192 of 2003
(From the Order dated 03.03.2000 in SC Case No. 07/2002 of
Jharkhand State Consumer Disputes Redressal Commission, Ranchi)
1. Smt. Anju Sharma
Wife of late Dhananjay Sharma
Resident of L5/8, Road No. 5
Kadma, Jamshedpur
District East Singhbhum
Appellants
2. Miss Suman
Daughter of late Dhananjay Sharma
Residing with and represented
By her mother, Smt. Anju Sharma
versus
1. Dr. D. Sinha,
Doctor, Gangotri Homes Pvt. Ltd. Medical Centre
Kadma, Jamshedpur
District East Singhbhum
2. Dr. R.K. Mishra
Doctor, Gangotri Homes Pvt. Ltd. Medical Centre
Kadma, Jamshedpur
District East Singhbhum
3. Mr. Ashok Jhingon
Director-in-Charge
Gangotri Homes Pvt. Ltd.
Kadma, Jamshedpur
District East Singhbhum
4. M/s. Gangotri Homes Pvt. Ltd., Medical Centre, Respondents
Kadma, Jamshedpur,
District East Singhbhum
BEFORE:
Honble Mr Justice R. C. Jain Presiding
Member
Honble Mr Anupam Dasgupta Member
For the Appellant: Mr. K.P. Toms and Mr. Vipin Nair, Advocates
For the Respondents: Mr. D.P.
Mukherjee, Advocate
DATED 14th JULY 2011
ORDER
Anupam Dasgupta The original complainants, Smt. Anju Sharma and her daughter Miss Suman have filed this appeal against the order dated 19.07.2002 of the Jharkhand State Consumer Disputes Redressal Commission, Ranchi (in short, the State Commission) in complaint case no. 07/2002. The complainants had approached the State Commission with allegations of medical negligence on the part of Dr. D. Sinha, Dr. R.K. Mishra, Mr. Ashok Jhingon, Director-in-Charge, Gangotri Homes (Private) Limited Medical Centre, Jamshedpur and the last-named Medical Centre in treating the late Dhananjay Sharma (husband of complainant no. 1) who, while suffering from malignant tertian (MT) malaria (also known as Plasmodium Falciparum or P. Falciparum or Falciparum malaria), was treated at the said Medical Centre during 01 02 August 2001 and died in the late evening of 02.08.2001. The complainants claimed compensation of Rs.12.90 lakh against the above-mentioned opposite parties (OPs) for their alleged medical negligence. However, after considering the pleadings, evidence and other documents / material brought on record, the State Commission dismissed the complaint by the impugned order; hence this appeal.
2. The essential facts of the case are that the late Dhananjay Sharma was brought to the above-mentioned Medical Centre and admitted thereto at about 3 p.m. on 01.08.2001 with complaints of fever and vomiting. He also produced a pathological blood report dated 31.07.2001 of Nilesh Diagnostic and Research Centre showing that he was suffering from MT malaria. After admission, he was examined by Dr. D. Sinha (OP
1), who immediately prescribed injections of Reg Q (Cinchona) 600 mg IM (TDS) and Cefexone 2 g IV (Stat), in addition to several other medicines and also put him on intravenous (IV) feed of 10% dextrose. Simultaneously, he ordered further blood tests. On the next morning (8 a.m., 02.08.2001), the dosage of Cefexone was reduced to 1 mg IV while that of Reg Q was maintained, with some variations in the accompanying medications. Results of the blood tests were also noted in the medical record at that time. The patient was described as afebrile with blood pressure (BP) of 130/82 and the general condition was described as OK except complaints of vomiting. However, by 4 p.m. on the same day (02.08.2001), the patients condition deteriorated with persistent vomiting and temperature rising to 102OF. It also appears that sometime at this stage, Dr. R.K. Mishra (OP 2) examined the patient and suggested further blood tests as well as continuation of injection Reg Q 600 mg (TDS). Some more blood tests, in addition to serum bilirubin, serum electrolytes, etc., were also advised and the prescribed medicines were altered. Still, it appears that the patients condition deteriorated rapidly. It also appears that sometime during this period, the attendants of the patient were asked to obtain blood for transfusion. Though no records are available, it appears that in the evening of 02.08.2001, the patient was referred to the Tata Main Hospital (TMH), Jamshedpur in view of the complications that he had developed. According to the impugned order, the patient was brought dead to the said Hospital though, once again, neither party has produced any records to that effect before us.
3. The specific allegations in the complaint were, inter alia, that the said Medical Centre was not equipped with facilities like Intensive Care Unit (ICU), ventilators, etc., in the absence of which the Centre was not in a position to treat patients of MT malaria because instances of complications like coma, renal failure, respiratory distress, etc., developing in such patients were common and management of such complications would require the above-mentioned facilities. The brother of the deceased, who took the latter to the OP Medical Centre, was unaware of the facilities available at the said Centre. However, since the OPs were fully aware of the absence of such facilities, they should have immediately referred the patient to a hospital equipped with such facilities instead of admitting him and starting his treatment. Secondly, during the treatment of the deceased patient, his electro cardiogram (ECG) was not taken at any stage, though an ECG was necessary to assess the cardiac condition of the patient before administering the drugs for MT malaria. Thirdly, the doses of injections and medicines administered to the patient were in excess of the prescribed standards as a result of which the patient developed complications in the evening of 02.08.2001. Finally, it was only with a view to shifting responsibility at the last stage that the OPs decided to refer the patient to the TMH when such referral was of no avail.
4. Each of these allegations was countered at length by the OPs, particularly OP 1 who was the treating physician and also Dr. R. K. Sharma, OP 2.
5. We have heard Mr. K. P. Toms, learned counsel for the appellants/complainants and Mr. D. K. Mukherjee, learned counsel for the OPs and carefully perused the record of treatment of the deceased at the OP Medical Centre.
6. We may note that before the State Commission, the complainants neither produced any medical expert nor any literature in support of the allegations. Further, while the learned counsel for the OPs produced detailed medical literature before us, the learned counsel for the appellants made no such attempt.
7 (i) It is an admitted position that the deceased came to the OP Medical Centre in the afternoon of 01.08.2001 though the report dated 31.07.2001 (date wrongly recorded as 13.07.2001 by the State Commission) of Nilesh Diagnostic and Research Centre showed that he had MT malaria. Thus, the deceased had apparently wasted a whole day before he sought treatment at the OP Medical Centre.
(ii) From perusal of the medical report it appears that the symptoms of the deceased at the time of his admission on 01.08.2001, as noted in the OPs medical record, were not such that he could be classified as a case of severe Falciparum malaria, i.e., with one or more symptoms like unarousable coma/cerebral malaria, acidemia/acidosis, severe monochromic, monocytic anaemia, renal failure, pulmonary oedema/acute respiratory distress syndrome (ARDS), hypoglycaemia, hypotension/shock, bleeding/disseminated intravascular coagulation, convulsions, haemoglobinuria, jaundice, etc., as described in Table 203-5, page 1288, Harrisons Internal Medicine, 17th Edition. The recorded symptoms were only fever, headache and nausea. The BP was 110/70 mm Hg and respiration was noted as clear. Thus, OP 1 who examined the patient on admission could have had no reason to clinically suspect a case of severe Falciparum malaria and hence of referring the patient immediately to another hospital which was better equipped to take care of any of these complications.
(iii) The first-line standard treatment for Falciparum malaria recommended worldwide by the World Health Organisation (WHO) consists principally of intra-muscular (IM) injection of artemisinin derivative (a drug used to treat patients of multi-drug resistant strains of Falciparum malaria) that has been found by large studies to be more effective than quinine (vide Harrisons, ibid, p. 1288). In this case, OP 1 administered Reg Q IM 600 mg (TDS), which he claimed in his written version to be such a derivative of artemisinin. In the absence of anything to the contrary, we have no reason to discard this claim. The recommended second-line treatment, in conjunction with the artemisinin derivative, comprises intravenous (IV) administration of an antibiotic like tetracycline (or doxycycline or clindamycin, vide Harrisons, ibid). OP 1 administered 2 mg IV of some antibiotic called Cefexone. Whether it was an antibiotic of the same variety as tetracycline, etc., is, however, unclear. As regards the dosages of the anti-malarial and antibiotic injections, those administered appear to be in line with the recommended dosages for body weight of about 60 kgs.
(iv) Apart from immediately starting the treatment for Falciparum malaria (based on the diagnostic report of Nilesh Diagnostic and Research Centre which showed presence of Falciparum malarial parasites in the patients blood sample), OP 1 also advised blood tests like Hb (haemoglobin), serum urea, serum creatinine, (random) blood sugar. Prima facie, the Hb test was intended to ascertain the status of adverse changes, if any, in the patients haemoglobin level (the principal intracellular protein of erythrocytes/red blood cells) which the growing malarial parasite first attacks and degrades. Serum creatinine test was clearly to check the renal function and serum sugar to check hypoglycaemia. These tests also appear to be necessary and quite adequate to start with, given the ordinary nature of the initial symptoms of the deceased patient.
(v) The blood test results noted in the medical record (time not mentioned) showed slightly lower-than-normal Hb (11.01), normal blood urea (16.30) and normal serum creatinine (0.80). These results, reportedly available by the evening of 01.08.2001, did not show any serious complication. Again according to the medical record, at 8 a.m. on 02.08.2001 the patient was afebrile, his blood pressure was 130/80 and general condition was OK except complaint of vomiting. The same regimen of medication was continued with the addition of an anti-emetic and some marginal variation.
(vi) The next set of medical notes of 4 p.m. on 02.08.2001 shows that the patients complaint of vomiting worsened so much that he was unable to take anything orally and his temperature shot up to 1020 F. At this stage, OP 1 recommended IV drip, Ringer Lactate and ice sponging and also asked for some blood tests like serum bilirubin, serum electrolyte, malarial parasites and Widal.
(vii) The sequence of events after 4 p.m. is not clear from the Medical Centre papers produced on record. However, from the written version of Dr. R. K. Mishra (OP 2) it is seen that OP 1 requested him (OP 2) at about 5 p.m. to take a look at the patient as his condition was quite serious.
According to the written version of OP 2, the patient was in a critical condition of which he (OP 2) apprised the (family) attendants immediately. He described the patients condition thus: fully toxic, persistent vomiting, with icterus, sub-conjunctival haemorrhage, a sign of bleeding diathesis setting in, BP 150/80 millimetre of Mercury, pulse regular. OP 2 also recorded his clinical observations as well as suggested course of treatment on the case papers. Among other things, he advised immediate blood transfusion. However, the patient developed the complication of ARDS (Acute Respiratory Distress Syndrome) even before the course of treatment recommended by OP 2 could be started and, therefore, there was no alternative but to transfer the patient to another hospital where he could be put under intensive care, including ventilator support. As a result, the patient was discharged from the Medical Centre and the attending members of the family were advised to take him to the Tata Main Hospital (TMH) so that he could be treated in an Intensive Care Unit (ICU) and put on ventilator support. Unfortunately, the patient died before he could be admitted to the ICU at the TMH.
8. The version of the OPs that the deceased Dhananjay Sharma was brought to Gangotri Medical Centre rather late after he was diagnosed to be suffering from MT Malaria appears to be valid from the pathological report dated 31.07.2001 and the record of admission at the OP Medical Centre. As already noticed, despite this delay in starting proper treatment for MT Malaria, the patients condition at the time of his admission could not be termed serious. Subsequent medical records also show that till the forenoon of 02.08.2001 the patient was managed reasonably well. Though it has been alleged that the medicines administered to the patient were in excess of the required dosages and some of them were altogether unnecessary, no medical literature has been cited or furnished by the appellants/complainants in support of this allegation. Hence, this allegation has to be summarily rejected. It is also difficult to agree with the appellants/complainants that the patient should have been necessarily subjected to ECG test before he was started on treatment for MT Malaria once again, there is no medical opinion/literature in support of this contention. As regards the alleged lack of facilities like ICU, ventilator, etc., at the Medical Centre, the contention of the OPs that these facilities were not mandatory for starting the treatment of all patients suffering from MT Malaria can be accepted to some extent. Had these facilities been medically essential for treatment of all MT Malaria cases, such treatment would have been possible only at the well-equipped hospitals and private Medical Centres, which would be of course numerically far fewer and hence treatment would be severely restricted. Primary health care with basic medical facilities supported by the availability of a hierarchy of higher levels of medical treatment in appropriate cases is the generally accepted model of public health facilities in a country like India. Moreover, as pointed out by the OPs, the father of the deceased was already an employee at the TMH and that hospital was quite close to their residence too. Therefore, if the appellants/complainants or the members of their family thought that ICU, ventilator, etc., were essential facilities for treatment of MT Malaria from which the deceased was suffering, they should have made arrangements to get the patient admitted straight to the TMH instead of going to the OP Medical Centre.
9. From the written versions of the OPs, however, it is not possible to see why and how the condition of the patient deteriorated so sharply in the afternoon of 02.08.2001. In his written version, OP 1 stated that he had examined the patient even at 2 p.m. on 02.08.2001 and found his condition to be satisfactory, except the vomiting. There is no record of this examination. Hence this claim has to be treated as an afterthought, an attempt to improve his case. The written version of OP 1 also seeks to create an impression that he had asked for the blood tests of bilirubin, electrolytes, malarial parasites and Widal after examination of the patient at about 8 a.m. on 02.08.2001. This is not borne out by the medical record because OP 1 recorded the advice for these tests on the page where he recorded (alongside) his observations of clinical examination at 4 p.m. of 02.08.2001. Finally, though OP 1 was the physician-in-charge of the patient, his written version is also totally silent on the sequence of events after 5 p.m. when the patient was examined by OP 2 (Dr. R. C. Mishra) at the request of OP 1. The papers on record also do not include a copy of any reference to the TMH with medical summary of the case detailing the critical status of the patient and recommending his urgent admission. On the other hand, as already noted, the complainants also did not produce any record of TMH to show that the patient was declared brought dead. But these are mere pointers to arouse suspicion. The important question is whether these conducts can, singly or collectively, constitute sufficient evidence to warrant conclusion of medical negligence on the part of any of the OPs in treating the deceased patient.
10. The law requires that to be held to be negligent a medical practitioner must be found to have either professed to possess professional skills and knowledge that he actually did not have or not brought to bear on the treatment of his patient the skills and the duty of care that an ordinary physician in the relevant branch of medicine would have. The appellants/complainants have not produced any medical literature or expert opinion to establish any of their allegations regarding the treatment. The delay on the part of the deceased or his immediate family to seek proper treatment for P. Falciparum Malaria is also not explained. Even the allegation that the patient was brought dead to the TMH is not established. On the other hand, despite the laches mentioned in paragraph 9 above, the OPs have produced a wide range of medical literature from reputed sources in support of their claims on each of the allegations. We are, therefore, of the view that the impugned order of the State Commission needs no interference. The appeal accordingly fails and is dismissed, with no order as to costs.
sd/-
.
[R. C. JAIN, J] sd/-
.
[ANUPAM DASGUPTA]