State Consumer Disputes Redressal Commission
1. M. Sivakumar And Two Others vs M/S. R.S.R Trinity Acute Care Hospital ... on 7 January, 2010
BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI Present Hon'ble Thiru Justice M. THANIKACHALAM PRESIDENT THIRU Pon. GUNASEKARAN B.A.,B.L., MEMBER - I O.P.NO.187/2000 DATED THIS THE 7th DAY OF JANUARY 2010 1.
M. Sivakumar
2. Minor Sangavi
3. Minor Satish Manikandan All are residing at No.20, Madha church Road Raja Annamalaipuram Chennai 600 028 (minor complainants 2 and 3 are represented by their father and natural guardian 1st complainant) .. Complainant Vs.
1. M/s. R.S.R s Trinity Acute Care Hospital Rep. by its MD A divisionof Trinity Nursing Home (P) Ltd., 33, Desikan Road, Alwarpet Chennai 600 004
2. Dr. Suganthi Rajagopalan (died and Legal heirs not brought in) Trinity Acute Care Hospital 33, Desikan Road, Alwarpet Chennai -600 004 . Opposite parties This petition coming on before us for hearing finally on 24.11.2009, upon perusing the material documents, and upon hearing the counsels for both the parties, and having stood over till this day for consideration, this commission made the following order.
Counsel for the Complainant: Ms. R. Dhanalakshmi, Advocate Counsel for the Opposite parties: Mr. S. Natarajan, Advocate M. THANIKACHALAM J, PRESIDENT.
1. This is a complaint filed under Sec.17 of the Consumer Protection Act, claiming a sum of Rs.15,00,000/- as compensation, for the loss and injury sustained by the complainants, due to the negligence and deficiency in service of the opposite parties.
2. The complainants case in brief is as follows:
The wife of the 1st complainant, and mother of complainants 2 and 3, by name Mrs. Meenalochini, was consulting the 2nd opposite party, when she conceived second time. Having followed the instructions given by the 2nd opposite party, Mrs. Meenalochini, expecting delivery, at the 3rd week of October, got herself admitted in the 1st opposite party hospital on 21.10.99, where she delivered a male baby at about 2.30 p.m., on the same day. After delivery, the 1st complainant was informed by the opposite parties and their staff that the health condition of Mrs. Meenalochini was good, and she was progressing well, after delivery.
3. The opposite parties have informed the 1st complainant at about 6.30 p.m that the blood is oozing out from the body of Mrs. Meenalochini, which could not be controlled and arrested. The bleeding would have been caused only due o the incomplete removal of placenta, immediately after delivery, which is nothing but a sheer negligence on the part of the opposite parties. The opposite parties never informed about this problem to the complainant, immediately after delivery. On hearing the condition of his wife, the 1st complainant was deeply depressed, and he was unable to make any other suitable alternative arrangements also to save the life of his wife. The opposite parties informed, that an urgent operation is required and the complainant also consented for the same, since he has no other alternative, and accordingly he signed all the papers without noticing and knowing the contents therein.
4. In the case of normal delivery, there could not have been any cause for oozing of blood, therefore, within an hour of delivery, must have been due to the negligent act of the opposite parties, in not attending the delivery properly, having unqualified staff. Mrs. Meenalochini died due to Hypovolimic shock Atonic PPH-cardiac arrest, as reported by the opposite parties, is not correct and the death was caused due to the deficiency in service on the part of the opposite parties , since she was hale and healthy at the time of the admission, as well as at the time of the delivery. For the premature death of the 1st complainants wife, the opposite parties alone should be held responsible, for which they should be directed to pay compensation of Rs.15 lakhs. Hence the complaint.
5. The case of the opposite parties in brief is as follows:
Mrs. Meenalochini had given birth to first child, thereafter she had two abortions, and thereafter only for her 4th pregnancy she came to the 2nd opposite party. She gave birth to male child on 21.10.99, in the hospital and after delivery everything was normal, even after episotomy.
The 2nd opposite party did episotomy, a cut made in the perineum at the time of delivery in almost all cases to facilitate easy delivery of child, to avoid irregular tears and was sutured immediately, and done under local anesthesia, which was informed to the complainants relatives, who were present. The bleeding which started two hours after was arrested and blood transfusion was done to restore the loss of bleeding. The opposite parties had carried out effective steps, to stop bleeding and transfusion was done, adopting all kind of precautions. The opposite parties had received the consent from the complainant after fully briefing the complainant about the emergency, necessitating to do hysterectomy, since uterus failed to contract, and this steps was taken as a last measure to stop bleeding and not otherwise, as falsely claimed in the complaint.
6. Mrs. Meenalochini, was suffering from DIC (Disseminated Intravascular Coagulation) a clotting disorder, bleeding from all parts of the body from punctures, for which immediate treatment was given, by the qualified team of doctors. As of emergency, hysterectomy was done only after getting the consent, and there was no negligence or deficiency.
7. The opposite parties have repeatedly informed about the episotomy done and the emergent hysterectomy, and unexpectedly Mrs. Meenalochini collapsed, for which opposite parties cannot be held responsible, as if they have committed negligence or carelessness. For the claim of the compensation, the opposite parties cannot be held responsible and the claim is also vexatious, highly imaginary, aimed to get unjust enrichment at the cost of the opposite parties. Other averments are denied as false. Hence it is prayed the complaint may be dismissed.
8. Points for determination are :
1. Whether the opposite parties have committed any medical negligence while treating Mrs. Meenalochini?
2.
Whether the opposite parties should be held responsible for the untimely death of Mrs. Meenalochini?
3. Whether the complainants are entitled to compensation, if so to what amount?
9. POINT NO.1 AND 2:
Tmt. Meenalochini, wife of the 1st complainant, mother of complainants 2 and 3, was admitted, in the 1st opposite party hospital, owned by the 2nd opposite party on 21.10.1999, at about 9.oo a.m, for delivery, with mild pain. Admittedly, as pleaded by the opposite party, Tmt. Meenalochini given birth to the 1st child, thereafter, she had two abortions, and after consulting with the 2nd opposite party, she conceived fourth time, and for this delivery alone, she was admitted in the 1st opposite party hospital. At about 2.25 p.m., on the same day, aided by episotomy, Meenalochini delivered a live male infant. Thereafter, some complications developed, which are inherent as said, leading to Postpartum Hemorrhage (PPH), for which emergency hysterectomy was also done by the 2nd opposite party. The attempt of the 2nd opposite party to control/ arrest PPH, even adopting final and sure method of hysterectomy, ended in vain, since after hysterectomy, she developed further complications, leading to cardiac arrest. In view of the said complication, she died on the same day at about 8.10 p.m., and the cause of death was Hypovolmic shock Attonic PPH Cardiac arrest. Thus the husband lost the wife, babies at their tender age, lost the mother.
10. The 1st complainant, accusing the opposite parties that due to improper treatment and incomplete removal of placenta, immediately after the delivery, by the negligence on the part of the opposite parties, issued notice, labeling the opposite parties as if they are responsible for the death of Meenalochini, for which a reply was issued, denying the averments, refusing to comply the claim of compensation. Therefore, as said above, the complainants claiming a sum of Rs.15 lakhs, under the heading loss of earnings, claiming a sum of Rs.2 lakhs, under the heading loss of gracious service to the family, under the heading loss of consortium of 1st complainant Rs.3 lakhs, under the heading loss of love and affection Rs.3 lakhs , as if deceased Meenalochini died in a road accident, where these kind of damages are available, calculated the total damage at Rs.25 lakhs, but restricting the claim at Rs.15 lakhs, has filed the complaint, seeking direction, which is opposed on various grounds.
11. In order to prove the allegations averments, in the complaint i.e., the negligence alleged against the opposite parties, on behalf of the complainant, 8 documents were exhibited, whereas Ex.B1 alone was marked on the side of the opposite parties, in addition to, parties have filed affidavits also.
12. The 2nd opposite party owns the 1st opposite party hospital. As seen from the records, she died, and the same was reported before this Commission on 24.1.2007, though the actual date of death was not known. The Consumer Protection Act contemplates, impleading legal heirs. Here, unfortunately, after the death of the 2nd opposite party, who treated Meenalochini, and who owns the 1st opposite party hospital, against whom, claims are made, her legal heirs were not brought on record. Therefore, it should be held at this distance of time, the case as against the 2nd opposite party abates, and the same should be dismissed as abated. As far as the 1st opposite party is concerned, since it is an institution, though have legal entity, it should be represented by a human agency, which was so represented by the 2nd opposite party during her life time. After the death of the 2nd opposite party, no one is impleaded to represent the 1st opposite party also.
Therefore, as such the 1st opposite party is unrepresented, and the hospital is there. This Commission had informed the above position, in the open court, and even thereafter, no steps had been taken.
Under the said circumstances, since the 1st opposite party is available, whether it is represented by the proper person or not, we are inclined to dispose the case on merit.
13. The complainants attributing negligence on the part of the respondents, have filed the case and therefore it is their prime duty, at the initial stage, to prove the medical negligence either by adducing expert evidence or otherwise.
In cases, where, we find the medical records are maintained properly, giving details regarding treatment given, the management adopted under the circumstances warranted, which are in accordance with the standard treatment prescribed under the Text, the expert opinion is necessary, to fix the negligence. On the other hand, the conduct of the opposite party, or the documents relied on by them or the admitted facts prove, prima facie negligence act, then the non examination of the expert, to prove the negligence alleged in the complaint, may not be fatal. On the other hand, if the documents available on record are insufficient, to prove the alleged medical negligence, then we may not have any option, except to dismiss the complaint, concluding that the alleged medical negligence or deficiency in service, are not proved.
14. As seen from Ex.B1, medical records, pertaining to the treatment given to Tmt. Meenalochini, she had suffered PPH, and the cause of death was cardiac arrest. In order to appreciate the facts in issue, and to find out whether the opposite party had performed her duty, as a diligent doctor, we have to understand, what is Post Partum Hemorrhage and other related complications, how they occur, in case of Post Partum Hemorrhage, what are the treatment to be given, how there should be effective managements etc.
15. My learned predecessor, probably after hearing the case to some extent, in order to understand more about the PPH, summoned Dr.Saraswathi, Director in-charge, Institute of Obstetrics and Gynecology, Government Women and Children Hospital Egmore, and she was examined before this Commission on 5.4.2007. Being an expert, not in dispute, she has given evidence regarding PPH, APH, how it happens, when happens, what are the drugs to be administered, surgical method to be followed, etc., not only by her experience, but also with reference to text books. For better appreciation, we feel the evidence given by her has to extracted as such:
Post-partum hemorrhage is a hemorrhage that occurs during the 3rd stage of labour and after delivery. When the hemorrhage occurs during the 3rd stage of labour, it is called 3rd stage hemorrhage. 3rd stage means stage of placental separation and expulsion. Thre is one entity called secondary PPH which occurs after 24 hours of delivery. During normal delivery the expected amount of blood loss will be somewhere around 115 to 230 ML. If it goes beyond 500 ML, it is called PPH. But according to our standard of women, even 300 ML loss is considered to be PPH in order to take prompt action. The complications depend upon mainly on the pre-natal health condition of the individual. And even though it is said to be associated with certain pre-disposing factors, sometimes it occurs unexpectedly. So it is a real problem to the Obstetrician. 60% could be anticipated. The pre-disposing factors are anemia in the ante-natal period, over distressed uterus like twins, hydramnios, tumours like Fibroid complicating pregnancy etc. and APH, any anesthetic effect, certain anesthetic drugs, prolonged labour, mismanagement of third stage of labour, certain drugs. These are all causes of atonic PPH where the uterus is not contracting well after the delivery of the baby. There is another category called traumatic PPH, which may be due to any truma in the genetal tract. Another cause is due to some coagulopathy. These are 3 categories.
3rd stage of labour consists of (1) plancental separation (2) placental expulsion. Only after the signs of placental separation are established, we have to help her for placental expulsion. Some times, the attending person whether he may be a doctor or anybody, over enthusiastically they may try to deliver the placenta even before it separates, which may cause problem.
Unnecessary kneading of the uterus before the placenta is separated wil lead on to hemorrhage.
Active management of 3rd stage of labour will definitely bring down the amount of blood loss following delivery which are being followed now-a-days.
How does it happen?
If the pregnant women goes for labour to the same person with whom she was having her ante-natal check-up, the identification of the high risk factors wojld have been done by them and after categorizing the patient as a high risk and low risk, she or he would have decided the place of delivery. If she thinks it is beyond her capacity, it is also possible that sometimes the hospital also may not be capable, the patient would have been referred in time which will prevent the PPH.
Methods of arresting it:
Mechanical method we use to compress the uterus by massaging. Mechanical means manual also. In mechanical methos, tampons would be inserted.
(2) Drugs:
Oxytocics like Methyl Ergometrin, Oxytocin, Prostoglandin F2 Alpha, PGE1 tablet.
(3) Surgical method: If it is not conroled with all these drugs, we go in for surgical method in a step-wise manner.
First we put brace sutures-B Lunch suture, Uterine artery ligtion, with Ovarian artery ligation, we then go in for internal iliac ligation, and at last if she is not going to respond to all these, if she is a multi i.e., mother of many children, we also sometimes go in for hysterectomy i.e., removal of uterus in order to save the mother (Highlighted) First thing is that we have to give blood in time, some times we may have to give blood products also. We have to take all measures to maintain her general condition.
If blood is not readily available?
In case blood is not able to be obtained, what should be done?
If the blood is not available, if they have the facility of giving Haemocele, it can be given only for time gaining and the patient has to be refered to higher institution where blood is available.
What text books say is that you should anticipate PPH in 100% of cases. In my view, practically it is not possible to anticipate all case of PPH.
Now a days, it is being instructed to give Oxytocics at the time of delivery of the anterior shoulder of the baby to prevent the blood loss to a minimum. Especially in cases where you anticipate PPH (over distended uterus, anemia without failure) we definitely follow this i.e., giving of Oxytocics at the time of delivery of the anterior shoulder of the baby.
Does every maternity centre have to be equipped with blood facility and man power?
It is always better to have it.
Keeping this in mind, recently our Govt. has come with the concept of setting CEmONC Centres i.e., Comprehensive Emergency Obstetric and Neonatal Care throughout our Stage which will have 24 hour facility for delivery. Caesarian and neonatal care.
It is not in normal practice to do BT, CT for all bleeding time and clotting time). But now a days it is being done by most of the doctors. It is always advisable to conduct BT, CT values may not be always the same. Sometimes, it can change at a later stage in certain conditions like excessive bleeding.
16. Clinical Obstetrics by Mudaliar and Menons gives us birds view regarding PPH and the related complications, including complications of the 3rd labour, where we find the following:
In the same book at page 277, under the chapter complications of the 3rd labour, we find the following:
The complications encountered in the third stage of labour are:
1.
Postpartum hemorrhage
2. Retained placenta
3. Uterine inversion POSTPARTUM HEMORRHAGE Definition Hemorrhage occurring after the delivery of the baby is termed postpartum hemorrhage (PPH). Hemorrhage occurring within 24 hours of delivery is termed Primary Postpartum hemorrhage and that occurring any time after 24 hours of delivery is called secondary postpartum hemorrhage.
PRIMARY POSTPARTUM HEMORHAGE Primary postpartum hemorrhage is defined as loss of 500 ml o more of blood occurring within 24 hours of delivery of the baby. Its incidence is about 5% of deliveries. This definition, while satisfactory from the point of view of obtaining comparative statistics, is not wholly acceptable from the clinical point of view.
The main causes of primary postpartum hemorrhage are . Uterine atony . Genital tract trauma . Retained placental fragments . Coagulatin disorders There are two varieties of primary postpartum hemorrhage
1. Atonic: Atonic hemorrhage is from the placental site and is due to the failure of the uterus to adequately contract and retract.
17. Effective management, Curative Treatment are contemplated, as under
object of treatment is to replace the blood lost and to stop the bleeding Repacement of lost blood: Atleast two large bore intravenous cannulas preferably 14 gayge, should be inserted. Blood should be drawn from crossmatching, estimation of hemoglobin, packed cell volume, coagulation tests, baseline urea and electrolytes. Fluid replacement should be commenced immediately. Blood transfusion should be started as soon as possible.
If the hemorrhage is still found to persist (in a small minority), traumatic factors must be considered. If tears of the cervix of vagina are found, they must be sutured. In their absence, with persistent bleeding, the management of these presents a problem. Intrauterine packing has been advocated by some. Coagulation failure may be a factor in some cases.
When bleeding continues inspite of all these, the obstetrician has to consider hysterectomy. Hysterectomy is the definitive treatment of persistent uterine atony.
18. The learned counsel for the complainants invited our attention to certain pages of Text Book of Obstetrics including Perinatology and Contraception, by D.C. Dutta, wherein we find some reference and the same can be reproduced here for better appreciation in order to fit in with the facts of the present case. It is the specific accusation of the complainants, that there was no complete removal of placenta, after delivery, and that is the main cause for the bleedings, leading to uncontrollable oozing of blood, which is called PPH.
19. Under the heading Management of 3rd state bleeding, it is said that If the patient is delivered under general anaesthesia, quick manual removal of the placenta solves the problem. In cases where ergometrine is given intravenously with the delivery of the anterior shoulder, manual removal is promptly done failing two attempts of controlled cord traction.
20. In the same book, steps of management are given for Atonic, which says The first step is to control the fundus and to note the feel of the uterus. If the uterus is flabby, the bleeding is likely to be from the atonic uterus. If the uterus is firm and contracted, the bleeding is likely of traumatic origin.
Atonic Uterus Step-1: (a) Massage the uterus to make it hard and express the blood clot. (b) Ergometrine 0.25 mg or Methergin 0.2 mg is given intravenously (c) Morphine 15 mg. is given intramuscularly (d) 5% dextrose drip is started and arrangement is made for blood transfusion
(e) To empty the bladder, if it is found full (f) To examine the expelled placenta and membranes, if available for evidence of missing cotyledon or piece of membrances. One should not, however, rely much on the comletences on the placental structures. If the uterus fails to remain firm and instead relaxes again with gush of bleeding, proceed to the next step.
Step:II :The uterus is to be explored under general anesthesia. Simultaneous inspection of the certix, vagina specially the para-urethral region is to be done to exclude co-existent bleeding sites from the injured area. Another dose of ergometrine is given and if necessary, an oxytocin drip may be started (10 units in 500 ml. of 5% destrose) at the rate of 30-40 drops per minute. In refractory cases, administration of 0.25 mg. of 15 methyl PGF2a either intramuscularly or transabdominal intramyomaterial route is useful to bring back the uterine tone. This may be repeated every 1-1.5 hours whenever. If the uterus still remains atonic, proceed to the next step.
21. Under the heading Retained Placenta, it is explained such as how it happened, suggesting remedies also. It defines The placenta is said to be retained when it is not expelled out even 30 minutes after the birth of the baby.
The risk also given under the heading Dangers, which reads as follows The risk involved in prolonged retention of placenta are:
(1)Haemorrhage (2) shock is due to (a) blood loss (b) at times unrelated to blood loss, specially when retained more than one hour and (c) frequent attempts of abdominal manipulation to express the placenta out (3) Puerperal sepsis (4) Risk of its recurrence in next pregnancy.
The management suggested the following:
During the period of arbitrary time limit of half an hour, the patient is to be watched carefully for evidence of any bleeding, revealed or concealed and to note the signs of separation of placenta.
The bladder should be emptied using a rubber catheter Any bleeding during the period should be managed as outlined in third stage bleeding.
22. Having the above facts in mind, it is to be seen whether the standard protocols were followed by the 2nd opposite party in this case. Before stepping into that stage, it is necessary to remember the guidelines given by the Apex Court, to fix the medical negligence.
23. The Apex Court of the land, in the celebrated case Jacob Mathew Vs. State of Punjab & Another, reported in (2005) 6 SCC 1, has held that it should be shown that the doctor against whom a medical negligence is attributed, did something or failed to do something, which in the given facts and circumstances, no medical professional in his ordinary sense, and prudence would have done or failed to do, and that the death should be the direct result of negligent act of the doctor, and the act alleged must be the proximate and efficient cause without the intervention of any other negligence, and in this kind of cases alone a doctor could be held responsible, warranting tortious liability, which is also reiterated in Nizam Institute of Mdical Sciences Vs. Prsanth S.Dhananka & Others, reported in 2009-4-LW Part 1, and followed in Martin F.D.Souza Vs. Mohd. Ishfaq reported in AIR 2009 Supreme Court 2049, wherein it is said A medical practitioner is not liable to be held negligent simply because things went wrong from mischance or misadventure or through an error of judgement in choosing one reasonable course of treatment in preference to another. He would be liable only where his conduct feel below that of the standards of a reasonably competent practitioner in his field. . It is further observed that an error of judgement may or may not be negligent. It depends on the nature of the error , further concluding The standard of care has to be judged in the light of knowledge available at the time of the incident and not at the date of the trial. Also, where the charge of negligence is of failure to use some particular equipment, the charge would fail if the equipment was not generally available at that point of time.
24. It is also the dictum of the Apex Court that Negligence in the context of the medical profession necessarily calls for a treatment with a difference. To infer rashness or negligence on the part of a professional, in particular a doctor, additional considerations apply. A case of occupational negligence is different from one of professional negligence. A simple lack of care, an error of judgement or an accident, is not proof of negligence on the part of a medical professional. So long as a doctor follows a practice acceptable to the medical profession of that day, he cannot be held liable for negligence merely because a better alternative course or method of treatment was also available or simply because a more skilled doctor would not have chosen to follow or resort to that practice or procedure which the accused followed. When it comes to the failure of taking precautions, what has to be seen is whether those precautions were taken which the ordinary experience of men has found to be sufficient; a failure to use special or extraordinary precautions which might have prevented the particular happening cannot be the standard for judging the alleged negligence
25. In Postgraduate Institute of Medical Educational and Research, Chandigarh Vs. Jaspal Singh and Others, the Apex Court reiterated the settled position regarding, the professional negligence which reads It is now well settled that a professional may be held liable for negligence if he was not possessed of the requisite skill which he professed to have possessed or, he did not exercise, with reasonable competence in the given case the skill which he did possess. It is equally well settled that the standard to be applied for judging whether the person charged has been negligent or not; would be that of an ordinary person exercising skill in that profession. It is not necessary for every professional to possess the highest level of expertise in that branch which he practices. Then coming to the burden of proof, it is the dictum of the Apex Court that In the medical negligence actions, the burden is on the claimant to prove breach of duty, injury and causation. The injury must be sufficiently proximate to the medical practitioners breach of duty. On the basis of the above settled proposition of law, the evidence in the present case has to be evaluated, when it is specifically alleged by the complainant, that the opposite parties have committed lack of care and cautions and the neglect, on the part of attending doctor.
26. In the proof affidavit of the complainant, several negligence or deficiencies are alleged, they are
1. that the complainant was not informed that the male child was born, aided by episotomy, and the opposite party had no stock of the blood group of the patient to meet the contingencies, which is negligence.
2. that bleeding would have been caused only due to the incomplete removal of placenta, immediately after delivery
3. that the opposite parties have failed to inform the condition of Meenalochini, if informed the 1st complainant would have made alternative arrangement to save the life.
4. that the opposite parties have not attended on her immediately, bestowed their proper care and attention to arrest the bleeding
5. that the 1st opposite party left Meenalochini, under the care of the person who are unqualified lacking necessary proficiency.
6. and that Meenalochini died due to Hypovolmic shock Attonic PPH Cardiac arrest, is incorrect.
27. The above negligences attributed, on the part of the opposite parties, are stoutly denied by the 2nd opposite party, who had filed proof affidavit. It is not the case of the complainant, that the 2nd opposite party is an unqualified person. It is the case of the 2nd opposite party, that she alongwith qualified team attended Tmt. Meenalochini and to that effect, case records and other connected records were maintained, which would throw much light, regarding the treatment given, which are in accordance, with the standard treatment prescribed by the standard text. When the qualified doctor viz. the 2nd opposite party, has filed sworn affidavit, and also relied upon Ex.B1, to prove the treatment given, stage by stage, to counteract the same, as if those methods are not sufficient or the managements adopted are incorrect, certainly an exert opinion is required. In this view, the non-examination of an expert, to prove the alleged medical negligence on the part of the opposite parties is fatal, to the present case, that too in view of the further fact, the procedure adopted by the 2nd opposite party as noted in Ex.B1, are not proved to be incorrect.
28. The learned counsel for complainant, doubted about the entries available in Ex.B1, and in support of the same, she invited our attention to paragraph 6 of the written version, filed by the 2nd opposite party, wherein it is stated that the complainants relatives, two elderly ladies who alone were in the hospital were informed of the episotomy done saw Meenalochini in good state after delivery gave coffee hence there was no suppression of performance of episotomy as alleged. The bleeding which started two hours later was arrested and blood transfusion was done to restore loss by bleeding. But in Ex.B1, we find there is an entry even at 2.25 p.m. miled attonic PPH- injection Methergin given. Based upon these notings, it is the submission of the learned counsel for the complainant, that even immediately after the delivery, there was bleeding and therefore the averments in the written version, as if bleeding started two hours later was arrested, and blood transfusion was done to restore the loss of blood, must be incorrect. By going through the entire record viz. Ex.B1, we find nothing wrong, in the statement made by the 2nd opposite party in the written version. At 2.25 p.m., on 21.10.99, though it is said mild Attonic PPH noticed, it is not the case of the 2nd opposite party, that it was serious, warranting blood transfusion. Only at 3.00 p.m, they have noticed bleeding, coming from, within the uterus, and at that stage alone the Gynecologist thought, transfusion of blood was necessary, and therefore blood also transfused, for which there is entry also at 3.00 p.m. Only in this context, if at all statement might have been given in the written version, and taking advantage of the same, it is not possible, to fix any medical negligence, as if the 2nd opposite party failed in her duty, as a prudent Gynecologist.
29. We have extracted from the standard text, to show what the steps to be taken are and how management should be adopted in case of PPH and remembering the same, the case sheet should be read, in order to find out, whether the 2nd opposite party followed the protocol. After delivery, in order to contract the uterus, as of rule, Methergin injection should be given immediately, which was also given as seen from delivery notes. It is not always mandatory, that massage should be followed, when PPH was noticed, as urged, when proper medicines are administered. Therefore, non-mentioning of any massage in the delivery note, and each and every steps taken to control the bleeding are not be noted in detail, may not a ground, to affix the negligence, when the major treatment which are so essential to control the bleedings are given, in the delivery note and other connected records.
30. The submission of the learned counsel for complainant, that for some time, after delivery, Tmt. Meenalochini was not at all attended by any qualified doctor, is also not supported by any materials, since, we find continuous monitoring, corresponding entry in the connected records.
The delivery notes reads:
Patient delivered a live male infant at 2.25 p.m aided by episotomy.
Child cried soon after birth 2.25 p.m Placenta Expelled at 2.30 p.m Mild Atonic PPH. Inj. Methergine given Syntocinon added of infusion Im Protodin given Episotomy repaired in layer C Catgut through out 5% GNS C 5 Units Cord Sutured GP O+ive 1 RL 1 lite C units 2 5 units 3 Calcium 4 BD 5 Bcomplxod 6 Cap. Ampicillin 7 BD 8 500 mg.
3.00 p.m Patient started bleeding PV profusely Inj. Methergin C Syntocinim IM given CX-
inspected- No tear- intact Bleeding coming from within the uterus Atonic PPH. Uterus managed Vagina packed. Bleding wsas not conrolled It was decided to do emergency hysterectomy Under GA, Abdomen Uterus was flabby Sub total hysterectomy done. Homeostatis 4 Units of fresh blood transfused. Patient developedbradycardia Adernsline inj. Given.
Dopamine developed bradycardia Adrenaline inj. Given. Dopamine infusion started. Abdomen closed in layer. Patient started oozing from the Episiotomy wound. Temporary pacer put to prevent cardiac arrest. Patient shifted to ICCU in on unstable condition.
Similarly, progress notes also would indicate the steps taken by the 2nd opposite party, which is also supported by her affidavit, we find no contra evidence as indicated above. The main accusation, repeatedly, said in the complaint, as well as in the affidavit is, Placenta was not completely removed. On the other hand the doctor has noted in the delivery notes, and the progress notes, about the removal of placenta, or its expulsion at 2.30 p.m. and in fact in the progress notes, it is stated placenta expelled in toto and inspite of that they have noticed miled PPH, for which Methergine injection, once again given, which is the standard medicine also, admittedly.
31. Continuous monitoring revealed, heart rate fluctuating, BP coming down, and bleeding not stopped. Therefore, according to the 2nd opposite party, a decision was taken for emergency hysterectomy. True, neither in Ex.B1, or in the affidavit filed by the 2nd opposite party, it is said that who has taken this decision, whether it is a collective decision of the team of doctors, nor the decision of the 2nd opposite party alone. Therefore the arguments was advanced, when there is no material to show how the decision was taken for hysterectomy operation, it should be construed, that there was medical negligence, and we find no logic in this argument. The 2nd opposite party being a qualified Gynecologist, was not barred from taking any decision, and it seems she being a qualified surgeon also. Therefore as decided by her, the patient was taken for emergency hysterectomy at 4.00 p.m, as per the progress notes available, and after satisfying, two units of blood given, and under GA, emergency hysterectomy was done at 4.00 p.m. It was also noticed, that heart rate diminished, and at about 4.30 p.m., patient developed bradycardiac, for which also medicines were administered, in addition to arranging Temporary transverse pacer introduced on table, for pacing, as well Femorel Catheter introduced for IV injection. Despite the standard procedure followed, the patient had not shown progress, and in fact as noted in the progress notes, BP not recordable, and at about 5.30 p.m, bleeding commenced from punctured side indicating DIC.
32. In this context we have to see, what is DIC:
DIC or Disseminated Intravascular Coagulation is a rare compication involving the malfunction of the blood clotting mechanism, as her body tries to break down the blood clot behind the placenta. DIC is a complicated process, but to try and oput it simply, it is the end result of two opposing physiological factors. On the one hand, massive amounts of small blood clots from throughout the extremities of the womans body. All these small clots use up most of the bodys platelet stores. The consequences of this is a lack of platelets in the rest of the womans body, causing widespread internal haemorrhaging. This is a life-threatening complication generall requiring the woman being admitted to an intensive care ward.
33. As guided above, in order to give better treatment, the patient was shifted to CCU, for further management. What are the procedure adopted and treatment given were noted in the progress notes, in between 5.45 p.m to 8.10 p.m, and for better appreciation, we reproduce the notes hereunder:
Patient Recd. From O.T. at about 5.45 pm with Enesthached Tube in SITU Pt. unstable Pt. was given ventilator support. And put on ASST. LMV HR was 130-140 Pulse feeble V+d Femoral pulse + BP Systolic 60 mm HG 6.30 PM Patient had a bradycardia 1 Amp. Of atropine IV given Pupils sluggish reaction 4mm Pulse not felt Peny partly cold BP 50 mm systolic 7.15 P.M IV fluids BP 50 mm HG Had another bout bradycardia 1 amp. Adrebnalin IV Adrorpine 1 amp. IV given 8.00 PM Had cardiac arrest stands CPR Cardiac massage given 25 mg. NA HC 03 given 1 Amp. Calci IV given BP ? 30 mm HG Pupils dilated Very sluggish reaction to light Pulse not felt Extremities cold 8.10 P.M Patient had a cardiac arrest Declared dead on 21.10.1999 Monitor showed no electrical activity Pupils dilated Not reacting to light Cause:
Hypovolmic shock Attonic PPH Cardiac arrest.
34. In the procedure so recorded above, no deviation was pointed out, even suggesting, that the procedure followed by the 2nd opposite party, while managing DIC, was incorrect, by examining an expert also.
Therefore, ignoring Ex.B1, in which we find the standard procedure adopted are noted, in view of the absence of any better evidence, we are unable to say, that the opposite parties have deviated from any procedures, or committed any deficiency, in service, or performed their duty carelessly, so as to say, that there should have been any deficiency in service. As and when required, blood transfusion had taken place, and admittedly before hysterectomy, consent was also obtained, thereby informing the complainant about the seriousness of the case, and the condition of the patient, and in the consent also, we are unable to find any fault. The accusation that no information was supplied regarding episiotomy, cannot come within the meaning of negligence or deficiency, since it is the routine practice, when there was some difficulty in delivery, some scar was made for easy delivery, which is known as episiotomy. It is not mandatory, for all the doctors, who perform this kind of duties, that they should preserve the blood group of the patient, which is impracticable also and therefore blood of the patient group not preserved, will not come within the meaning of the deficiency. As and when required, the 2nd opposite party obtained blood and transfused and despite the best care taken, as the inherent risk available in delivery, bleeding continued, hysterectomy also failed and unfortunately DIC occurred, thereby destiny ruled, terminating the life of Meenalochini, for which it is not at all possible, to blame the opposite parties. Except the bard allegations, that unqualified doctors and nurses have attended the patient, we find no evidence to support the same, either in the form of affidavit or otherwise, and we cannot presume the qualified 2nd opposite party, would have got the assistance of unqualified doctors, or the nurses, while attending delivery.
35. Reading Ex.B1, meticulously coupled with the guidance, available in the medical text, we find no negligence and therefore as ruled by the Apex Court, as pointed out, awarding compensation, on the ground of medical negligence in this case, is beyond reach. Thus, analyzing the facts and circumstances of the case, from all possible angles, the irresistible conclusion that we are constrained to reach are that the opposite parties have not committed, any medical negligence, while treating Meenalochini, and for the untimely death of Meenalochini, they cannot be held responsible also. Hence these two points are answered against complainants.
36. POINT NO.3:
In view of our findings on point Nos. 1 and 2, the complainants are not entitled to any relief, much less compensation. Hence, this point is answered accordingly.
37. In the result, the complaint is dismissed, but in the facts and circumstances of the case, the parties are directed to bear their respective costs.
PON GUNASEKARAN M. THANIKACHALAM MEMBER-I PRESIDENT Exhibits of complainant A1 Death certificate A2 17.03.00 Salary certificate A3 21.10.99 Receipt issued by Devaki Hospital, Chennai A4 21.10.99 Receipt by CHS Medical Centre Chennai A5 25.02.00 Suit notice A6 06.03.00 Reply notice A7 15.04.00 Rejoinder A8 Further reply Exhibit of the opposite party B1 Medical records PON GUNASEKARAN M. THANIKACHALAM MEMBER-I PRESIDENT INDEX : YES / NO Rsh/d/mtj/OP Orders