State Consumer Disputes Redressal Commission
Ravindrabhai S Verma vs Sheth Vadilal Sarabhai Genral Hospital ... on 31 January, 2022
Details DD MM YY
Date of Judgment 31 01 2022
Date of filling 05 10 2011
Duration 26 03 10
BEFORE THE CONSUMER DISPUTES REDRESSAL COMMISSION,
GUJARAT STATE AT AHMEDABAD.
Court-3
Complaint NO. 59 of 2011 Dt: 31.01.2022
1. Ravindrabhai S. Verma
2. Master Devesh Ravindrabhai Verma
3. Kumari Yamika Ravindrabhai Verma
4. Kumari Yashika Ravindrabhai Verma
C/o. Shri Satyaprakash Verma
Vora Mansuri‟s Chawl,
Ahmedabad. ...Complainants
Vs.
1. Sheth Vadilal Sarabhai General Hospital &
Sheth Chinai Maternity Hospital
The Superintendent,
V S Hospital,
Near Ellisbridge,
Ahmedabad.
2. Municipal Corporation of Ahmedabad
The Municipal Commissioner,
Danapith, Ahmedabad. ...Opponents
Appearance: Mr. Rajiv N. Mehta, representative for the Complainant
Mr. M. K. Dudhiya, Ld. Advocate for the Opponent No.1
Coram: (Shri S. N. Vakil, Judicial Member)
(Smt. J. Y. Shukla, Member)
Order by Shri S.N. Vakil, Judicial Member
1. This is against medical negligence.
2. The complainants - along with twinkal Ravindrabhai Verma, died pendent light filed this consumer complaint against Sheth Vadilal Sarabhai General Hospital and Municipal Corporation of Ahmedabad that opponent No.1 known as V.S.Hospital is providing medical K.S.P CC-11-59 Page 1 of 26 treatment to public at large on payment of consideration and free of charge to some patients. His wife Twinkalben being pregnant was under
treatment of Dr. Raginiben Toshniwal who performed caesarean and delivered a male child in 2007. During Diwali 2009, she was found pregnant again and was taken to Dr. Raginiiben who after examination confirmed that she was pregnant and therefore carried out sonography and gave expected date of delivery to be around 24th June, 2010, instructed her to take rest and reasonable care for the second pregnancy. Sometime later it was also confirmed that she would delivered twins, growth of both babies are satisfactory and there is nothing to worry. She was taken for routine checkup to Dr. Raginiben on or about 27th March, 2010 and had informed that except low Hb count there is no difficulty, prescribed certain medicines to increase Hb level. During night intervening between 3rd and 4th April, 2010, she complained for watering discharge from her private part and was immediately taken to Dr. Raginiben. She was not available and reported to be out of station. Dr. Kothari, incharge of hospital, after preliminary examination informed that delivery process has started, she would require hospitalization urgently, as no gynecologist is present in his hospital gave reference note for admission in V. S. Hospital where she was taken. The doctor on duty examined her and advised for indoor hospitalization and confirmed that delivery process had already started as there is leak from vagina. She was given different medicines and carried out sonography also. He informed that because of low Hb count she would require rest and treatment to prevent infection at the time of delivery, and was kept under observation and given treatment. Many doctors and assistant doctors K.S.P CC-11-59 Page 2 of 26 examined her and drips were started. On 4th morning the in charge nurse informed him that Dr. Parulben, Dr. Rinaben and Dr. Krantiben have been informed, they will assess the condition of the patient and will decide for operation procedure if any. During the whole day her blood pressure, pulse and temperature etc. were observed and noted, many pathological investigations were carried out and was kept on higher drugs. However, when she was found unable to bear adequate pain for delivery, the doctors decided to perform caesarean on the next day i.e. 5th April. On next day morning, she was otherwise OK and was talking to relatives when she was taken to operation theater for caesarean around 10.30 a.m. After about hours or so he was informed that twins have been delivered successfully but since they are weak required to be put under observation of qualified child specialist. When she inquired about her condition he was informed that suturing procedure is going on and as soon as the procedure will completed she will be taken to ward. He waited for about hours but no doctor gave any signs of bringing her to ward. It gave him a suspicion that something has happened inside the theater but the doctors are not disclosing the correct facts. He time and again had asked the concerned attendance near the OT but of no help as the doctors were not ready to disclose anything about the event that might have taken place. When more than sufficient time elapsed in between and the patient was not put to ward he straightway asked to one of the doctors (name unknown) trying to entering the operation theater, he was for the first time informed that patient has still not regain consciousness and all doctors are trying their level best to make her conscious. At that point of time he had realized why doctors were not K.S.P CC-11-59 Page 3 of 26 disclosing facts that patient is in comma and not able to regain consciousness. He was then informed that during the operation patient‟s condition become critical after delivery and lost her consciousness. When the doctors were asked about the future action, they said that all depends upon the almighty god and they are not in position to say that when she will get consciousness. Even after passing of 17 months, she has not regained consciousness, that itself suggested that there was gross carelessness, mistake, fault, imperfection and short coming in the quality of services that was expected from the qualified doctors who participated in the said caesarean operation during her hospitalization. It was heard from some of the staff members that the anesthetists committed the gross mistake and had given excessive dose and that has resulted into permanent damage to her brain. Despite 17 months have passed there is no sign of regaining her consciousness and it speaks for itself. Immediately after operation for few days the doctors in staff were showing humanitarian approach towards her and relatives, but as time passed, it become routine for them, they are not taking her proper care and asking the complainant to get discharged and treat her at home.
After three months from the date of operation, the opponent doctors, nursing staff and other paramedical staff started behaving strangely and suppress all papers pertaining to her treatment and were trying to convince him that they did their best and there was no negligence or carelessness on their part and therefore he should get discharge. When he demanded complete details of the incident took place inside the operation theater and the treatment given therein, the doctors looked each other and refused to disclose anything. They were treating the K.S.P CC-11-59 Page 4 of 26 complainant and his wife like untouchable. Their un-humanitarian approach, lack of carelessness, gross negligence towards her has compelled the complainant to think otherwise and is of the opinion that just because he had issued notice to remind them their gross carelessness and resultant damage to her the doctors are keeping bias and not providing proper care for treatment. Had the doctors have taken care diligently, with required promptness and with reasonable care and caution while performing operation her condition could have been avoided. only because of their gross negligence and carelessness in attitude, the complainant have suffered a lot during her unconsciousness for the 17 months. He spent Rs. 3 lakhs towards her treatment. In notice dated July 2010 he called upon them to pay Rs. 18 lakhs but because of time and recurrent expenses had now increased the amount of expenditure incurred till date, claims Rs. 21 lakhs. She died during pendency on while still remaining unconsciousness. After the notice the doctors have gathered all the documents from every corner and kept in their custody and the complainant is now not permitted to see those papers to which he is legally entitled to. The opponents had willfully not supplied any documents to establish the actions taken by them are genuine and there was no negligence in their part. He under the circumstances, justified if he infers that opponent wants to suppress the correct facts and it is most likely that to save the skin from liability, they would produce false and fabricated documents. For this deficiency in service they claim Rs. 21 lakhs towards compensation with reasonable rate of interest and Rs. 40,000/- towards costs.
K.S.P CC-11-59 Page 5 of 26
3. The defence of hospital, the opponent No.1 vide written version is of total denial. The complainants suffers from non-joinder of Dr. Krutiben Deliwala, Dr. Rinaben Patel (gynec), Dr. Gargiben Bhavsar and Dr. Shrutiben Shah (Anesthetist). No case papers of Dr. Raginiben are produced. When water had discharged, at that time Dr. Raginiben was not present in hospital nor incharge Dr. Kothari started treatment but forwarded her to opponent 10 Km away which shows their negligence. She was admitted in opponent hospital on 4.04.2010 at about 3.30 a.m, at that time as per the history taken she was under category of high risk patient. She had complaint of discharging water for 6-7 days, WBC count was 25,300, there was caesarean in previous delivery, had TB before 2 years and was operated for goalbledder also. Under these circumstances she having been pregnant was considered high risk patient. It was informed to her relatives and high risk consent was also taken. Necessary investigations were immediately carried out so also her blood report, her WBC count was 25,300 against normal of 4,400 to 11,000, which showed infection during pregnancy and had its effect in blood, till bringing her to opponent hospital. She had discharged water since long and had many other complications also considering which her condition was serious. It was explained to her relatives also. On 4.04.2010 at 3.40 a.m. and 5.04.2010 at 11.30 a.m. after taking consent of her husband and brother-in-law in order to control the infection antibiotic medicines and injection were immediately given. She had low HP count in which level of infection in blood increases which is required to be controlled. Her Hemoglobin was 8.3% which being higher than 7%, blood infusion was not required. But the blood were kept ready if need arises. She was also K.S.P CC-11-59 Page 6 of 26 examined by neuro-medicine doctor and neurosurgeon on 5.04.2010. Her MRI report and necessary test report were carried out on 6.04.2010. Thereafter also she was examined and treated by hospital, nuro-medicine doctor. If the water has discharged and infection occurred the delivery should be done within 24 hours. She gave birth by caesarean to two children. During operation there was no surgical negligence or nor any surgical complication arose. Expert opinion of two gynecolosist Dr. Atul Munsi and Dr. Tushar Shah was obtained. She was treated sympathetically eversince was admitted in the hospital. The work of administering anesthesia was done by Dr. Gargiben Bhavsar, according to whom she was under high risk category. Before caesarean, her pregnancy and medical investigations were carried out. In addition her blood pressure was examined which was 140/90 and pluses was 155 per minute. Moreover, before operation, aesthetical investigation were also carried out and thereafter was given spinal anesthesia. The doctor was present at the time of observations during operation, her BP, Pulse rate, percentage of oxygen etc. were all observed and noted during operation. In addition all the observations during operation and that done after 5.04.2010 to 7.04.2010 have also been noted. The approved procedure was adopted. There is no negligence of carelessness of anesthetist, doctors or any expert opinion of two expert senior anesthetist, Dr. Mahesh S. Kapadia and Dr. Mukesh Vakil have also been taken. It is a case of Amniotic Fluid Embolism, which cannot be predicted nor prevented. Rests is denied. There was no negligence or deficiency in services.
K.S.P CC-11-59 Page 7 of 26
4. Heard Shri Rajiv N. Mehta, for the complainant and Advocate Shri Milanbhai Dudhia, for the Opponent - V. S. Hospital and read written submissions.
5. Complainant‟s deposition is same as the complaint is.
6. Dr. Mahesh Kapadia, an anesthetist doctor deposes that he is practicing since long and is able to give export opinion as per his experience Anesthetist line. He looked and read records of treatment papers produced by Sheth V. S. Hospital and also read the history of patient Twinkal Ravindra Verma on medical case paper of the V. S. Hospital. Whenever I gave opinion, I always to through the record of treatment papers and patient‟s history and that is conversant with the fact of case on the basis of all relevant medical case papers given to him. In his report, he had put up his observations and various possibility in such case as per medical practice. (page-198) so also Dr. Atul Prafulbhai Munshi-a gynecologist, Dr. Tushar Shah-a gynecologist and Dr. Mukesh Vakil-an anesthetist have deposed the same as aforesaid.
7. Dr. Tushar N. Shah gave opinion (page -82, 83 = page 226, 227): on looking the records and history of the patient taken from the Xerox copy of all relevant papers, following observations are noted: Patient was referred from outside after premature rupture of bag of water. PPROM for (4-5) days. With choreoamnionitis. WBC count 25000 per cmm report dated 4/4/2010. She had past history of laparotomy for gall stone 3.5 years back. History of C-section before 3 years. History of pulmonary TB before 2 years. Taken AKT for 1 year. A fair trial was given for vaginal delivery at V5 after emergency admission and after removal of nylon wire. (wiring done outside in private). Decision of C-section was taken after K.S.P CC-11-59 Page 8 of 26 consultation of senior doctor, Proper high risk informed consent was also taken before surgery. Pre-op Anesthetic reference was done. Proper antibiotic coverage was given prior to surgery. Help of neonatologist was duly taken. It is seen that up to the plan of surgery due care was taken by team of gynecologist and anaesthologist at V. S. Hospital. Now, the problem accur during surgery at the time of delivery of second baby of Twin. There is sudden collapse of the patient. There are various possibilities in such case: 1. There may be cardio respiratory depression following S.A. Immediately due care was taken by anesthetist Doctor with intubation of the patient. 2. There may be pulmonary embolism during the delivery of placenta. Here also adequate care and resuscitation is made. 3. Because of infection in the amniotic membrane there is septicemia, which leads to Hypotension & shock. She was already given higher antibiotic and IV fluid to prevent and to take care of such problem. 4. She had a history of T.B. and was given a treatment for one year. Some times in such cases, Adrenal insufficiency can occur which lead to hypotension. The collapse of the patient in O.T. in this case doesn't seem to be a sequel of negligence. She was treated properly before and during surgery by a team of Gynecologist and anesthesiologist. Here she was also treated by neurophysician in tertiary care of V. S, Hospital. Looking at all these things I can opine that it is unfortunate on the part of the patient to get this problem. But she was given a due care at V. S. Hospital by gynecologist, anesthesiologist and neurophysician and there is no question of negligence in care of the patient. In cross examination (page 223-225) he answers that he has been practicing as gynecologist since 1982 and has given his opinion to V. S. Hospital. Before some 14 K.S.P CC-11-59 Page 9 of 26 years he was resident doctor in V. S. Hospital and thereafter has never served there. He admits that in case of caesarian operation, many a time a patient goes into comma during or after the operation and that with respect to his opinion he had zerox of entire case papers; that he gave opinion three months after the incident, that he has not met any other doctor who might have examined the patient, that when he gave opinion he was informed that a patient is living but under comma; that he has never seen or examined the patient and that has given his report in 2012; that he came to see details as to first issue from the case papers, that meaning of PROM is pre-mature rapture of membrance (bag of water); that „P‟ is typed twice in the issue and infact should be for once only. He cannot say whether the PPROM and PROM are two different situations or not but meaning of both this words as per his opinion are same. He denies that the history mentioned in his opinion was not taken from the case papers but from the paper given in writing by the parties. He admits that in his opinion "pre operative anesthesia reference was done" was written from anesthetist note (page-84); that the anesthetic note page-84 was written down in the operation theater; that the possibility of the first as mentioned in his opinion page-80, may arise from spinal anesthesia during anesthesia. He admits that if this spinal anesthesia is given in right quantity at right place, there does not remain possibility of depression respiration; he then answers that he does not agree to the said preposition and denies that problem does not arise if the anesthetist doctor immediately does procedure of spinal anesthesia with taking due care. He cannot say within what time incupation is required to be done had the care taken immediately after cardiac respiratory depression and K.S.P CC-11-59 Page 10 of 26 says that the answers could be given by anesthesia only. He cannot say the problem occurring to this patient was due to surgery or anesthesia. In his opinion post mortem is required to be done in order to know and then answers that anesthetic has to do the incupation process. To the question what are the symptoms of amniotic fluid embolism he answers that if cardiac respiratory depression occurs immediately and BP starts falling and if treatment is not given immediately then cardiac respiratory arrest would occur to the patient. He answers that it is not necessary that in case of amniotic fluid embolism during first hour right vertical failure would occur to the patient. To the question which measures are required to diagnose in case of amniotic fluid embolism, he answers that ECCO cardiography is to be done. In case of pulmonary embolism also the said could occur, he answers that in case of amniotic fluid embolism debris would circulate in the blood and denies that this debris would cause septimia or that debris could be known by pathologist procedure. He admits that DIC can be done in case of amniotic fluid embolism, he admits that cardiac respiratory can happen not because of high spinal anesthesia but spinal anesthesia, which includes all this procedure. He has not seen any report showing blood coming out from mouth and nose of the patient, when he examined the record. He denies that he has given opinion wrongly by (page-80) with intention the helping the doctors.
8. Dr. Mukesh Surykant Vakil, consultant anesthesiologist and interventional pain specialist, teacher and head for DNB programme, gave opinion (page 119 to 122) herewith, in which, following factors are considered to come to conclusion for opinion about this case. 1. Patient had c.s. done earlier in august 2007. Thereafter she had undergone K.S.P CC-11-59 Page 11 of 26 laparoscopic cholecystectomy. She had then developed pulmonary koch's and had taken treatment for 1 year. Hence the claim made by the husband that she had no health problem after first c.s. in 2007 seems to be not correct. 2. The reference note sent by dr. Ragini Toshniwalis is not attached in the bunch sent to me. 3. After she was admitted in V.s. hospital she was examined by many doctors round the clock, many tests were done, was given iv. fluids, was given many higher drugs in the period from admission to operation. This is accepted by husband in his petition. 4. As per the records of the hospital she was given inj. betnesol 3 cc i.m.at 4-00 p.m. on 4/4/10 i.e after admission in V.S. Hospital, Labour Room. This is in interest of mother and babies. 5. Laboratory results after admission shows low hb% of 8.33, t.c.25300 (n-82,l- 12), suggessting infection. 6. High risk consent for mother and babies are taken both by anaesthesia and obstetrics dept. 7. Blood gas arterial reports at 3-30 p, m. on 5/4/10 shows high Po2 of 461.6. This indicates high oxygenation. 8. Fibrinogen degradation products capital is positive in 1:8 dilution, suggests haemolysis or coagulation disorder. 9. Physician's visit at 12-20 p.m. and neurophysician's visit at 2:20 p.m., indicates that patient responds to deep painful stimulus, pupils are not dilated and reacts to light. 10. Anesthesia senior doctors and resident doctors have managed the case in operation theatre and ICU very well, they have taken rounds many times and attended the case in the days following operation. Clinical factors: 1. There were findings of infection in preoperative period. 2. The spinal anesthesia was uneventful till babies were delivered, this is indicated by the fact that both babies are normal even now. 3. In time from second baby was delivered she suddenly had K.S.P CC-11-59 Page 12 of 26 fall in B.P., fall in pulse rate, difficulty in breathing, gasping respiration and unconsciousness. 4. Within sooner time only her B.P, pulse became normal she started breathing, no sign of bleeding afterwards. This was following prompt action taken by team of anesthetists, in the form of giving oxygen, intubation, giving many drugs to raise B.P, pulse, and also steroids was given. 5. Immediately physician was called for opinion, and advise was followed. 6. Arterial blood gas reading taken at 3:00 p.m. Does not suggest hypoxia or acidosis. Opinion: There seems to be two possibilities in this case. First amniotic fluid embolism; in this condition squamous cells of foetus goes to maternal circulation and block the blood flow in lung blood vessels. Hence patient collapses. It is very rare,1:8000 to 1:20000. phase-1 acute fall in B.P. difficulty in breathing, cough, cyandsis, convulsions, fluid in the lungs and hypoxia can occur. If patient survives, she goes in phase-2 where there is massive bleeding and coma. Survival is uncommon. Mortality is 60% or more. Arterial blood gas report shows hypoxia, hypercarbia. Complications in those who survives are pulmonary oedema, heart failure, bleeding diathesis. Neurological deficit persists, coma in this case. In the present case this possibility is likely as the events developed and end result in form of coma are matching with the book presentation. It is managed promptly and properly by doctors. Furhter diagnosis of amniotic fluid embolism is by exclusion of other causes of hemodynamic instability and no tests can confirm positively the diagnosis. Factors against this possibility are:
Usually even after the treatment, B.P, pulse, respiration does not become normal within minitues as has happened in this case. Patient has never developed pulmonaru oedema, cyanosis, heart failure, bleeding disorder. K.S.P CC-11-59 Page 13 of 26 Arterial blood gas is not showing hypoxia and acidosis as should occur in amniotic fluid embolism. Possibility 2: High or total spinal anesthesia. When inj. sensorcaine is used this condition can occur in first half hour. Patient will stop breathing, fall in B.P., pulse rate can occur. Can be reversed by waiting and giving oxygen and drugs if given promptly. Cerebral hypoxia can occur if it goes unnoticed for some time before being managed. Factors against this: The episode was managed immediately by team of doctors, not one doctor. Hence no chance of going unnoticed even for seconds. In further chief examination (page 228 to
237) deposes that he is HOD of anesthetist at Sal Hospital, so also in 2010. He gave expert opinion on the basis of patient case paper of to the then medical superintendent of V.S. Hospital. In cross examination (page 228-237) he answers that he has been working as anesthetist doctor for last 41 years. He does not exactly show today whether his opinion was asked for orally or by writing. The medical record has been sent back to V.S.Hospital. It was not said to give opinion as the patient went in comma. I was asked to give opinion as to whether what has happened to the patient had any relation with the complainant in the commission or not. For anesthesia, it is important to make clinical examination of the patient. When I was asked to give opinion the patient was living and it is true that he did not examine the patient before giving opinion. I was sent majority of medical record but the patient appeared to have been admitted with Dr. Raginiben Toshniwal but those papers were not sent to me. In history paper‟s diagnosis column of the sheet "G3, P1, A1, L1+8 M A + TWINS + pre cs + Leaking" is written where he cannot say what is meant by "G3, P1, A1 L1+P/V", twins means two children, pre cs shows K.S.P CC-11-59 Page 14 of 26 that was done upon the patient previously, P/V shows that water was discharging from vagina. He has given opinion with respect to injection Betnisol was given during treatment to the patient, with respect to which he has given his opinion. He cannot give opinion as to other treatment.
As to whether she was anemic when taken for operation, he answers that in his opinion hemoglobin is mentioned as 8.33 from medical record. In this case because of hemoglobin 8.33 the patient cannot be termed anemic because she came in emergency. The other reason given her total count to be 25,300 upon which it cannot be decided that she was anemic and considering this hemoglobin of 8.33 cannot be said to be abnormal. In blood examination report her hemoglobin was 8.33. In his report her total count were 313000 and WBC count was 25300. Therefore, her total count cannot be said to be 25300 to which he answers that total count 313000 shows plate let count and in medical terminology total count means WBC count. Before giving opinion he did not find it necessary to call for detailed papers or additional details as to the treatment. He admits that for giving opinion it is important to know which drugs were given to the patient during treatment. There was no question for him to know who gave anesthesia but he came to know only which medicine was given. Whether it is true that when she was taken for operation, considering her condition she was high risk patient, he answers that it is not necessary that by giving "BUPIVACAINT" in high risk patient as anesthesia, patient‟s B.P. goes down, there may be chances but B.P. would not go down in all cases. He was shown note during treatment on page 52 and confirms that therein in a note written at 12:30 it has been written of patient suddenly collapsing; and that the note is for noting K.S.P CC-11-59 Page 15 of 26 down by medical unit. In the said notes there is mention as to patients condition as "G3 P1, A1, L1". He shown page 85 and answers that it is the note by anesthetist who gave anesthesia to the patient. He admits that it would be a serious matter if neurological problem arise to patient in case when anesthesia was given. To the question whether in case of spinal anesthesia it would be exceedingly very serious if neurologist problem arises to the patient. He answers that it is said serious only in any case if neurologist problem arises after spinal anesthesia given. There are different reasons for neurological problem. He admits that by administrating of Bupivacaint Drug two kinds of blockage, namely Motor and Sensory are produced and answers that for this only the drug are being given. B.P. getting down has no relation with Motor and Sensory blockage but has relation to 3rd block known as sympathetic block. To the question whether by peripherial venous pulling there occurs effect on volume reseptor, he answers that tone of the value known as volume reseptor value may reduce if sympathetic block occurs. By this there would not be effect on cardiac nerve but may be on blood circulation but that is very rare and if precaution were taken it would not occur. He answers that there would not be effect by sympathetic block on cardiac nerve activity but cardiac nerve may get suppressed if there occurs high spinal. Heart beats may slow down by effect of blood circulation. Heart beats getting slow down is known as bradycardiac. He was shown page- 84 and confirms that it is mentioned in the middle portion that after delivery to baby patient developed sudden brady cardiac, and the time of note is 12.30. To the question what happens if full dose of spinal anesthesia is given in manangis spinal cord, he answers that unit of 4 K.S.P CC-11-59 Page 16 of 26 CC is normally considered full dose and in case of cesarean ordinarily dose of 2 CC is being given. Even if 4 CC or 2 CC are given, by its effect motor block and Sensory block sympathetically block occurs and to get it anesthesia is given. To the question whether high oxygenate mentioned in the opinion is based on the report after oxygen given after the patient collapsed, he answers that at 3.30 p.m. in the blood PO2 was noted down as 461/6 which shows the oxygenation was high. To the question whether it is true that the reason the patient went into comma was lack of oxygen, he answers no, it can be one of the reason but it cannot be definitely said that it was the only reason. To the question what other reason than lesser oxygen could be for her going into comma, he answers 2 main reasons can be 1st Amniotic Fluid Embolism and 2nd complication of spinal anesthesia. To the question whether it is true that Amniotic Fluid Embolism is said to be the condition that arises when the amniotic fluid goes into blood circulation, he answers that he is not agreeable that if amniotic fluid goes into blood circulation there would in all case be water entered in lungs, but the water in uterus goes into blood circulation. To the question if such uterus water goes with the blood in lungs pipe the condition of pulmonary edema may arise, he answers it may occur or may not also. If uterus liquid goes into lungs pipe first of all trouble in breathing occurs and if for that reason oxygen does not go sufficiently hypoxipa occurs and oxygen may reduce as part of pathological. Uterus water if goes into blood circulation and by that goes into lungs pipe, then heart failure may also occur thereby. Disseminated Intra Vascular Coualagopathy may occur. To the question whether in this case any bleeding is mentioned to have occurred to the patient, there in K.S.P CC-11-59 Page 17 of 26 the record he answers that there is no mentioning of bleeding to have occurred around 12:30 but the gynecologist had noted that uterus was not contracted and therefore gave massage to the uterus and thereafter it contracted. Whether page No. 16 and 17 shown from this file were there in the case papers given to him for opinion or not he answers that he cannot say today. On page 17 there is mentioned uterus got lastly contracted. He answers in affirmative that reports of BT, CT and PT are necessary for confirmation of DIC and says that report of APTT and Dimer are also necessary. But he does not remember whether before operation reports of BT, CT and PT were obtained and he show them or not. It is true that brain and retina are sensitive to reduced oxygen. To the question what symptoms appear on patient body if oxygen does not reach to the brain for 10 second, he answers that even if oxygen does not reach brain its symptoms would arrear on the body but 10 seconds for that is not necessary. The book on anesthesia by Wylie is considered authentic. On page 134 of its 5th addition is written "The brain and retina are very sensitive to oxygen lack. The sensitivity of the latter can be demonstrated by pressing gently on the side of one's eye to occlude the blood supply and within ten seconds observing a dark area advancing over the affected field.", and answers that 10 seconds is mentioned as to what happened if blood is not reached and it is with respect to eyes and not brain. Brain tissues may become dead if oxygen is not got by brain cotex. If oxygen is given within 5 minutes to such tissues there is possibility of such tissues reviving, but it is rare. It is not possible to answers without anything that in this case the brain tissues of the patient had died and answers that it can be known by Post Mortem. In K.S.P CC-11-59 Page 18 of 26 the present case the patient started breathing of her own lately and thereafter remained alive on natural air for years and therefore it cannot be said that all the tissues of the brain had died. It is true that respective part would stop working by so much tissues as are dead. Nephrosis at dead tissue cannot be seen by nacked eyes because it is inside the skull. He was shows PM Report (page 210) and asked whether it shows the brain tissues getting dead during operation against the column as to condition of brain, he answers that he is not agreeable to it having said so. After death blood supply to the brain stops and thereby signs would be seen of brain tissues being dead in blood of brain. To the question ventricles gets dialated in case of brain cortex is not revived, he answers that pathologist can answer this question better, he cannot. In such case when brain cotex does not revive the brain swells and answers that because the brain swells it does not revive. Anesthetist should avoid in every case gasping. If breathing stops or (Gabharaman occurs) is considered sign of gasping. It is not necessary that it only does not occur, but its treatment is to be done immediately. He denies to have given wrong opinion to help doctors of V.S.Hospital.
9. In this summary procedure it has been difficult to resolve whether history of AKT or TB was or was not all given. We are not convinted that the history record has been a brought up one. Not even by history of discharging water against water discharged or nothing of no discharge. For complainant, so many such documents are used during examination of witnesses and shown during arguments. There is nothing to show whether the complainant asked for documents or what documents were asked for and what were not provided.
K.S.P CC-11-59 Page 19 of 26
10. For the complainant Res ipsa loquitur is pressed into. In Jacob Mathew (Dr.) Vs. State of Punjab & Anr., III (2005) CPJ 9 (SC), Res ipsa loquitur is shown to be a rule of evidence which in reality belongs to the law of torts. Inference as to negligence may be drawn from proved circumstances by applying the rule if the cause of the accident is unknown and no reasonable explanation as to the cause is coming forth from the defendant and in para-27 ... ... even in civil jurisdiction, the rule of res ipsa loquitur is not of universal application and has to be applied with extreme care and caution to the cases of professional negligence and in particular that of the doctors. Else it would be counter productive. Simply because a patient has not favourably responded to a treatment given by a physician or a surgery has failed, the doctor cannot be held liable per se the doctrine of res ipsa loquitur. It was argued that by this principle the opponent be held liable. Now, it is clear that when the claimant has advanced cause of incident as excessive spinal anesthesia whereas the opponent Amniotic Fluid Embolism as its cause. Therefore, the cause being not unknown and incident as to the cause coming forth from defendant, it is clear that rule of res ipsa loquitur is not applicable here. V. Krishna Rao Vs. Nikhil Super Speciality Hospital, Appeal No. 2641 of 2010 (Supreme Court) in its para-46, gives illustrations where the principles of res ipsa loquitur have been made applicable in case of medical negligence as "Where a patient sustained a burn from a high frequency electrical current used for "electric coagulation" of the blood [See Clarke Vs. Warboys, The Times, March 18, 1052, CA 7]; Where gangrene developed in the claimant's arm following an intramuscular injection [See Cavan Vs. Wileox (1929) 44 D.L.R. (3d) 42]; When a patient K.S.P CC-11-59 Page 20 of 26 underwent a radical mastoidectomy and suffered partial facial paralysis [See Eady Vs. Tenderenda (1074) 51 D.L.R. 3d) 79, SCC]; Where the defendant failed to diagnose a known complication of surgery on the patient's hand for Paget's disease [See Rietz Vs. Bruser (No.2) (1979) 1 W.W.R. 31, Man QB]; Where there was a delay of 50 minutes in obtaining expert obstetric assistance at the birth of twins when the medical evidence was that at the most no more than 20 minutes should elapse between the birth of the first and the second twin [See Bull Vs. Devon Area Health Authority (1989), (1993) 4 Med. L.R. 117 at 131.]; Where, following an operation under general anesthetic, a patient in the recovery ward sustained brain damage caused by bypoxia for a period of four to five minutes [See Coyne Vs. Wigan Health Authority (1991) 2 Med. L.R. 301, QBD]; Where, following a routine appendisectomy under general anesthetic, an otherwise fit and healthy girl suffered a fit and went into a permanent coma [See Lindsey Vs. Mid-Western Health Board (1993) 2 L.R. 147 at 181]; When a needle broke in the patient's buttock while he was being given an injection [See Brazier Vs. Ministry of Defence (1965) 1 LL. Law Rep. 26 at 30]; Where a spinal anesthetic became contaminated with disinfectant as a result of the manner in which it was stored causing paralysis to the patient [See Roe Vs. Minister of Health (1954) 2 Q.B, 66. See also Brown Vs. Merton, Sutton and Wandsworth Area Health Authority (1982) 1 All ER. 650]; Where an infection following surgery in a "well-staffed and modern hospital" remained undiagnosed until the patient sustained crippling injury [See Hajgato Vs. London Health Association (1982) 36 0.R. (2d) 669 at 682]: and Where an explosion occurred during the course of administering anesthetic to the patient K.S.P CC-11-59 Page 21 of 26 when the technique had frequently been used without any mishap [Crits Vs. Sylvester (1956) 1 D.LR. (2d) 502]." These being case of spinal anesthesia does not fall therein.
11. C. P. Shreekumar (Dr.) Vs. S. Ramanujam, II (2009) CPJ 48 (SC), imports Jacob Mathew's case (supra) "the onus to prove medical negligence lies largely on the claimant and that this onus can be discharged by leading cogent evidence. A mere averment in a complaint which is denied by the other side can, by no stretch of imagination, be said to be evidence by which the case of the complainant can be said to be proved. It is the obligation of the complainant to provide the facta probanda as well as the facta probantia". The complainant has not examined any medical side expert; and seeks to above by the record.
12. Dr. Mukesh Suryakant Vakil (DW-2) deposes that normal unit of 4CC is considered full dose, and in case of caesarian normal unit of 2CC is being given. He was shown page-52 and asked that the note at 12:30 shows to have her suddenly collapsed. In cross-examination so many other pages were also shown to the witnesses. Hence it is no ground that o doctor from the opponent filled affidavit in support. Page-84 anesthetic note shown to us, shows Dr. Savan to have injected caesarian heavy 0.5% 2CC and monitoring is done by Dr. Ankita. Therefore, it proves that there was no excessive dose.
13. For the complainant a book titled "A practice of Anesthesia" 5th Adition, edited by Wylie is submitted which at page-127 under the head "Oxygen and Associated Gases" deals with "The failure of the tissues to receive adequate quantities of Oxygen is variously described as anoxia, hypoxia, or oxygen lack, but strictly interpreted anoxia means total lack of oxygen. K.S.P CC-11-59 Page 22 of 26 The lack of oxygen represents a severe hazard to the tissues and has been aptly described by Haldane as causing "not only stoppage of the machine, but also total ruin of the supposed machinery". Under ordinary conditions the body has certain regulatory mechanisms which prevent the tissues from suffering oxygen deprivation, but during the course of anesthesia oxygen lack may become a factor of prime importance." In the said chapter under head "Effects of Hypoxia" condition of "Organ Failure"
page 134 it is written as under: "The brain and retina are very sensitive to oxygen lack. The sensitivity of the later can be demonstrated by pressing gently on the side of one's eye to occlude the blood supply and within ten seconds observing a dark area advancing over the affected field. Cerebral function is a sensitive indicator of oxygen lack changes of mood occur and performance gradually deteriorates leading to confusion and loss of consciousness the circulation is arrested. The time taken for the brain to stop functioning to the extent of loss of consciousness is called its "survival time". The "Revival Time" is the time beyond which recovery of function is not possible. The brain cortex survival time is about 0.5 min whereas its revival time is about 5 min."
14. It is argued: the notes on Page 85 (described as Anesthetist Note Per operative chart) shows pulse were "feeble P 45" at 12.25. Condition of patient was shown as "gasping" at that time. Notes on Page 84 also reads:
"At 12.30: after delivery of 2 baby, patient developed sudden "Bradycardia" (p 45) pulse very feeble" Interestingly both these papers are described as Anesthetist‟s note. It is argued that presumption can be made that condition of the patient deteriorated around 12.15 and thereafter. Contrary to this, page 52 (reference note written to give K.S.P CC-11-59 Page 23 of 26 emergency call to Physician from operation theatre) reads as under:
"5/4/10 12.15 pm: Pt. is in OT. During surgery pt suddenly collapsed. kindly examine pt and do needful." "Urgent 5/4/10 12.20 pm. Call attended & pls see note on back of this page" Page 53 reads as under: "5/4/10 12.30 pm: S/b MUF (Dr. NNS sir informed). T/F/R case reviewed. M/o noted. Pt unconscious. Pt goes into shock while operation for LSCS. Intubation done". These notes tend to indicate that condition deteriorated prior to 12.15 p.m. and emergency call was given to physician too and who seems to have attended call at 12.20 pm. However record of anesthetist and physician shows "intubation done" at 12.30 pm. It is argued that when patient was collapsed or gasping, why "intubation"
was not done is unexplained. If we read all these notes as it stands, the basic question is at what time actually patient lost consciousness? The doctors were answerable to explain this. These are the arguments for the complainant, vide written synopsis.
15. Now, the first child 1.1 kg was born at 12.05 p.m. and the second also 1.2 kg at 12.07 p.m. on 05.04.2010 (page-42). On 5.04.2010 12.15 p.m., note (page-52), MUF reads "R/W/C of patient is G3, PA4+84A+ pre CS + Twins pregnant patient is in OT. During surgery, patient suddenly collapsed, kindly examine patient and do needful" and at 12.20 p.m. it writes "urgent" at 12.20 p.m. The note dated 5.04.2010, 12.30 p.m. (page-53) reads S/B MUF (Dr. NNC sir informed), T/F/R reviewed, M/O noted, patient unconscious, Pt goes into shock while operation for LSCS intubation done, f/b pulse 176/ min, BP 150/90 mmhg, SPO2 100% with AMBU, then it records CNS unconscious, advise urgent ECG and Cardio Ref BT, CT, PT with INR, urgent RF + elect CBC (XRPA) dg. From K.S.P CC-11-59 Page 24 of 26 anesthetic note (page-85) reads dated 5.04.2010 at 12.15 pulse 150, BP 124/88, CPO2 99%; 12.25 Feble (pulse 44), BP -, SPO2 85%, then "(gasping tracheotomy" then it speaks about injections and immediate intubation 100% and ..........; at 12.35, 158, 75/38, 99% then it speaks of injection; at 12.40, 156, 122/78, 99%; at 12.45, 170, 136/80, 99% stop; at 1.00, 145, 145/92, 100% .......... Now, when this note at page-85 is read the gasping developed between 12.25 and 12.35 and that it is against this gasping is noted to have been immediately treated with medicine and immediate intubation and 100% O2, which would clearly go to show that the time 12.20 on page-52 does not seem to be the correct one, it being clearly later than 12.20 i.e. after 12.25. Anesthetic note page-84 at 12.30 reads "after delivery of second baby patient developed sudden trachy cardia gasping breathing. SPO2 85% and pulse very feeble, injection ....... Immediately patient is intubation with number 7.5 ...... at the same time at 12.30 notes of Dr. NNS (page-53) shows "case reviewed" MO noted and all intubation, pulse, SPO2, BP with ambu and advise as aforesaid as seen above. Here it is clear that it is not that the patient was treated with intubation, abmu etc. only after Dr. NNS came, because he only reviewed the case which also makes it clear that injection, intubation and ambu were already given prior to his coming. So also OT notes (page-16, 17) while noting down the step by step procedures on page-17 writes, the same doctor who wrote on page-52, the timings of information to the doctor as at 12.00 p.m. "patient suddenly collapse and developed apnea after the delivery of second baby, patient „immediately‟ intubated and 100% O2 given by the ET Tube by the anesthetic person". Then it goes to speak about closer of uterus and K.S.P CC-11-59 Page 25 of 26 other steps. This also shows that there was intubation with 100% O2 by anesthetic person immediately. Therefore, there is no time lag between gasping, and intubation and injection etc. Therefore, the complainant‟s contention, not pleaded, fails. It has been found that anesthetic doctor, doctors immediately took steps for treatment, intubation, and thereby her going into comma is not as a result of failure on the part of doctors after her gasping. The above two doctors have given two possibilities. One is this which they have discarded and the other as AFE. There is nothing to definitely discard this other possibility of AFE. Therefore, the complaint deserves to be dismissed as disproved.
16. For the reason stated the complaint deserves to be dismissed, for which following order is passed.
FINAL ORDER
i) Complaint No. 59 of 2011 is dismissed.
ii) No order as to costs.
iii) Copy of the judgment be provided to the parties free of charge.
Pronounced in the open Court today on 31st day of January, 2021.
(J.Y.Shukla) (S.N.Vakil)
Member Judicial Member
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