State Consumer Disputes Redressal Commission
Singeshwar Singh vs Apex Hospital on 22 March, 2023
Cause Title/Judgement-Entry STATE CONSUMER DISPUTES REDRESSAL COMMISSION, UP C-1 Vikrant Khand 1 (Near Shaheed Path), Gomti Nagar Lucknow-226010 Complaint Case No. CC/90/2018 ( Date of Filing : 19 Mar 2018 ) 1. Singeshwar Singh S/O Sri Ram Janm Singh Niwasi Flate No. B/02 C Nicate Mahaveer Mandir Mohalla Ardali Bazar Post and Thana Cant Distt. Varanasi 221002 ...........Complainant(s) Versus 1. Apex Hospital To Prabandhak and Sanchalak Dr. S.K. Singh To Apex Welfair Pvt Ltd Corporate Office D.L.W. Hidil Road Post and Thana Lanka Distt. Varanasi 221004 ............Opp.Party(s) BEFORE: HON'BLE MR. Rajendra Singh PRESIDING MEMBER HON'BLE MR. SUSHIL KUMAR JUDICIAL MEMBER PRESENT: Dated : 22 Mar 2023 Final Order / Judgement राज्य उपभोक्ता विवाद प्रतितोष आयोग , उत्तर प्रदेश , लखनऊ। सुरक्षित परिवाद सं0-90/2018 सिंगेश्वर सिंह पुत्र श्री राम जन्म सिंह, निवासी-फ्लैट संख्या-बी0/02 सी0, निकट महावीर मन्दिर, मोहल्ला-अर्दली बाजार, पोस्ट व थाना-कैण्ट, जिला-वाराणसी। पिन-221002. ........... परिवादी। बनाम 1.
अपेक्स अस्पताल द्वारा प्रबन्धक एवं संचालक डॉ0एस0के0 सिंह द्वारा अपेक्स वेलकेयर प्राईवेट लिमिटेड, कार्पोरेट कार्यालय डी0एल0डब्ल्यू0, हाईडिल रोड, पोस्ट व थाना-लंका, जिला वाराणसी, पिन-221004.
2. ओरियण्टल इंश्योरेंस कम्पनी लिमिटेड द्वारा मुख्य क्षेत्रीय प्रबन्धक, क्षेत्रीय कार्यालय, तृतीय तल, 43, एल0आई0सी0 इन्वेस्टमेंट बिल्डिंग, मोहल्ला, पोस्ट व थाना - हजरतगंज, जिला लखनऊ, पिन-226001.
.............. विपक्षीगण।
समक्ष:-
1. मा0 श्री राजेन्द्र सिंह, सदस्य।
2. मा0 श्री सुशील कुमार,सदस्य।
परिवादी की ओर से उपस्थित : श्री प्रकाश चंद्रा अधिवक्ता।
विपक्षी सं0-1 की ओर से उपस्थित: श्री विष्णु कुमार मिश्रा अधिवक्ता।
विपक्षी सं0-2 की ओर से उपस्थित: कोई नहीं।
दिनांक :- 26.04.2023 मा0 श्री राजेन्द्र सिंह , सदस्य द्वारा उदघोषित निर्णय संक्षेप में परिवादी का कथन है कि परिवादी नार्दन कोल फील्ड लिमिटेड, जिला-सिंगरौली, मध्य प्रदेश में महाप्रबन्धक के पद पर कार्यरत था जहॉं से वह दिनांक 31-01-2018 को सेवानिवृत्त हुआ।
उपरोक्त पद पर कार्यरत रहने की अवधि में परिवादी अपनी पत्नी श्रीमती मंजू सिंह के साथ दिनांक 28-03-2016 को कार पंजीयन संख्या-एम0पी0-66-सी0-2576 से डेहरी से गोरबी की तरफ आ रहा था। उक्त कार को कार चालक अशोक दुबे चला रहा उक्त कार जब रात्रि के लगभग 08.00 बजे बंजारा होटल के आगे औडी मोड़ पर पहुँची तो उक्त कार वाहन चालक की लापरवाही से एक ट्रक पंजीयन संख्या-यू0पी0एच0-9107 से टकरा कर क्षतिगस्त हो गई। उक्त मार्ग दुर्घटना में कार चालक समेत कार में बैठे परिवादी तथा उसकी पत्नी की चोटें आईं। उक्त दुर्घटना के सम्बन्ध में थाना-अनपरा, जिला-सोनभद्र में प्राथमिकी अंकित कराई गई प्रथम सूचना रिपोर्ट इस परिवाद पत्र का संलग्नक संख्या-01 है।
उपरोक्त दुर्घटना के उपरान्त स्थानीय लोगों ने पुलिस की मदद से हमें निकटवर्ती नेहरू शताब्दी चिकित्सालय जयन्त (सिंगरौली) पहुँचाया, जहॉं प्राथमिक उपचार देने के उपरान्त परिवादी की पत्नी की स्थिति को देखते हुए दोनों लोगों को अग्रिम इलाज के लिए वाराणसी रिफर कर दिया। परिवादी तथा उसकी पत्नी श्रीमती मंजू सिंह को वाराणसी रिफर किए जाने से पूर्व इस अस्पताल में घायल श्रीमती मंजू सिंह की इंजरी रिपोर्ट तैयार की गई थी।
वाराणसी में अच्छे इलाज की अपेक्षा में परिवादी व उसकी पत्नी को अपेक्स अस्पताल में दुर्घटना के दूसरे दिन, दिनांक 29-03-2016 को सायंकाल के लगभग 05.00 बजे भर्ती कराया गया और उनका इलाज प्रारम्भ कर दिया गया। इलाज की प्रारम्भिक प्रक्रिया पूरी किये जाने व परीक्षणोपरान्त चिकित्सकों की यह राय बनी कि परिवादी व उसकी पत्नी को जिस तरह की चोटें आईं हैं उन चोटों के इलाज के लिए सर्जरी किया जाना उचित एवं आवश्यक होगा।
दिनांक 30-03-2016 को जिस दिन उपरोक्त अस्पताल के चिकित्सक परिवादी की पत्नी की सर्जरी करने के लिए इच्छुक थे उस तिथि को परिवादी की पत्नी की शारीरिक अवस्था अस्थिर थी। उनका ब्लड प्रेशर बढ़ा हुआ था, नाड़ी की रफ्तार बढ़ी हुई थी और शारीरिक अवस्था सर्जरी किए जाने की अनुमति नहीं दे रही थी। चिकित्सकों ने परिवादी के अनुरोध पर सर्जरी की कार्यवाही टाल देने पर अपनी सहमति दे दी।
उपरोक्त सहमति बनने के कुछ देर बाद ही उपरोक्त अस्पताल के चिकित्सक डॉ0 एस0के0 सिंह के पुत्र डॉ0 स्वरूप एस0 पटेल जो कि उसी अस्पताल में हड्डी रोग विशेषज्ञ हैं, ने अपने पिता से बातचीत करने के उपरान्त परिवादी को बिना सूचित किए व आपरेशन किए जाने वाले मरीज की शारीरिक अवस्था से पूर्णतया अनभिज्ञ रहते हुए और आपरेशन किए जाने से पूर्व ऐसे मरीज व मरीज के किसी भी तीमारदार, परिवादी समेत मरीज के पुत्र अथवा पुत्री की अनुमति बिना उन्हें वार्ड से आपरेशन थिएटर में भेज दिया।
आपरेशन थिएटर में भी मरीज का प्राथमिक परीक्षण किए बिना उन्हें बेहोश किए जाने की कार्यवाही प्रारम्भ कर दी गई। आपरेशन थिएटर में उक्त मरीज को बेहोश करने की कार्यवाही डॉ0 सौरभ (एनेस्थेटिस्ट) द्वारा डॉ0 ए0के0 सिंह व उनके पुत्र डॉ0 एस0एस0 पटेल की उपस्थिति में की गई। आपरेशन थिएटर में ऐसी कार्यवाही प्रारम्भ किए जाने से पूर्व एनेस्थेसिया देने वाले उपरोक्त चिकित्सक ने इस बात की कोई पड़ताल नहीं की कि क्या मरीज शारीरिक रूप से एनेस्थेसिया की स्थिति सम्भालने योग्य है, क्या आपरेशन थिएटर में आपरेशन से जुड़ी हुई समस्त औपचारिकताऐं पूरी हैं तथा क्या आकस्मिकता की स्थिति में आकस्मिक स्थिति को सम्भालने के लिए पर्याप्त संसाधर (चिकित्सक व चिकित्सकीय उपकरण) हैं।
उपरोक्त तथ्यों की बिना कोई जांच किए उपरोक्त एनेस्थेटिस्ट चिकित्सक ने परिवादी की पत्नी को एनेस्थेसिया दिया। उपरोक्त चिकित्सक द्वारा अपने चिकित्सकीय कर्तव्यों के अनुपालन में की गई यह घोर चिकित्सकीय लापरवाही परिवादी की पत्नी पर बेहद भारी पड़ी और उन्हें आपरेशन टेबल पर ही हृदयघात (कार्डियक अरेस्ट) हो गया।
विपक्षी चिकित्सकीय संस्थान के आपरेश थिएटर में जिस समय परिवादी की पत्नी को हृदयघात (कार्डियक अरेस्ट) हुआ उपरोक्त आकस्मिक स्थिति को सम्भालने के लिए न तो आपरेशन थिएटर और न ही चिकित्सालय में कोई विशेषज्ञ चिकित्सक उपलब्ध था और न ही उपरोक्त चिकित्सालय का ऐसे किसी विशेषज्ञ चिकित्सक से कोई सहमति या अनुबन्ध था जिसे आपातकालीन स्थितियों में बुलाया जा सके। उपरोक्त के अभाव में परिवादी की पत्नी को किसी विशेषज्ञ चिकित्सक की सुविधा उपलब्ध नहीं हो सकी। उपरोक्त के साथ ही विपक्षी चिकित्सकीय संस्थान के आपरेशन थिएटर में आपरेशन के वक्त कोई ऑक्सीजन सिलेण्डर नहीं था, न ही मरीज को ऑक्सीजन दिए जाने सम्बन्धी अन्य उपकरण ही उपलब्ध थे। उपरोक्त विशेषज्ञ चिकित्सक तथा चिकित्सकीय उपकरण की कमी का परिणाम यह हुआ कि परिवादी की पत्नीको हृदयघात (कार्डियक अरेस्ट) हुआ तो उसकी पत्नी के हृदय ने उस रूप में काम करना रोक दिया जो साधारण रूप से एक मानव का हृदय करता है। हृदय का सामान्य कार्य प्रभावित होने पर हृदय से मस्तिष्क को पहुँचने वाले खून का पहुँचना व ऑक्सीजन का पहुँचना भी प्रभावित हो गया। जिस तथ्य को विपक्षी चिकित्सकीय संस्थान में कार्यरत चिकित्सक प्रथमत: समझ पाने में पूर्णतया असफल रहे और दूसरे ऐसी आपातकालीन स्थिति को सम्भालने के लिए चिकित्सालय में न तोचिकित्सक उपलब्ध थे और न ही चिकित्सा उपकरण।उपरोक्त चिकित्सकीय लापरवाही के परिणाम स्वरूप परिवादी की पत्नी के मस्तिष्क को पहुँचने वाली ऑक्सीजन व खून की कमी के कारण उनका मस्तिष्क गम्भीर रूप से प्रभावित हो गया और परिवादी की पत्नी कोमा की स्थिति में चली गई।
उपरोक्त प्रतिकूल घटनाक्रम हो जाने पर अस्पताल के चिकित्सक स्वयं भयभीत हो गए और वह बाहरी चिकित्सक (डॉक्टर सौरभ, एनेस्थेटिस्ट) जो अस्पताल को अपनी सेवाऐं प्रदान करते थे अस्पताल से गायब हो गए और वह दोनों चिकित्सक जो अस्पताल के मालिक थे उनके द्वारा मरीज के सम्बन्ध में परिवादी को सही जानकारी उपलब्ध नहीं कराई जा रही थी।
उपरोक्त परिस्थितियों से निराश होते हुए परिवादी ने एन0एस0सी0 अस्पताल, सिंगरौली के चिकित्सा प्रभारी से बात की, उन्हें समस्त तथ्यों से अवगत कराया और उनसे इस सम्बन्ध में सहायता किए जाने का अनुरोध किया। परिवादी के अनुरोध पर उपरोक्त चिकित्सा प्रभारी ने डॉ0 पंकज कुमार जो कि उक्त अस्पताल में एनेस्थेसिया विशेषज्ञ के रूप में कार्यरत थे, को अपेक्स अस्पताल वाराणसी जाने का निर्देश दिया और वास्तविक तथ्य की जानकारी प्राप्त करने के लिए कहा।
एन0एस0सी0 अस्पताल के चिकित्सा प्रभारी के आदेश एवं निर्देश पर उपरोक्त चिकित्सक महोदय रात्रि के लगभग 10.00 बजे अपेक्स अस्पताल पहुँचे और उन्होंने न केवल चिकित्सकों को बुलाकर मरीज की स्थिति जानने का प्रयास कियावरन् स्वयं मरीज (श्रीमती मंजू सिंह) का निरीक्षण भी किया।
मरीज उपरोक्त का निरीक्षण करने के उपरान्त उपरोक्त चिकित्सक की यह स्पष्ट राय थी कि परिवादी की पत्नी की स्थिति बेहद गम्भीर है और यह स्थिति लगातार बिगड़ती जा रही है और मरीज की शारीरिक अवस्था को सम्भाल पाने में उपरोक्त चिकित्सालय के चिकित्सक पूर्णतया असहाय हैं।
एन0एस0सी0 अस्पताल के चिकित्सक डॉक्टर पंकज कुमार (एनेस्थेसिया विशेषज्ञ) से इस प्रकार की जानकारी मिलने पर परिवादी सहित उसका पूरा परिवाद हतप्रभ हो गया और यह समझ पाने की स्थिति में नहीं था कि हमें अब आगे क्या करना चाहिए। थोड़ी देर बाद स्थिति सम्भलने पर उपरोक्त चिकित्सक व परिवारीजनों की सलाह से अपेक्स अस्पताल से रेफरेन्स लैटर बनवाकर मरीज को दिल्ली ले जाने की सहमति बनी। जिस सहमति के आधार पर उपरोक्त चिकित्सालय से रेफरेन्स लैटर बना दिए जाने का अनुरोध किया गया और रेफरेन्स लैटर प्राप्त किया गया।
इसके बाद परिवादी अपनी पत्नी को एयर एम्बुलेंस के माध्यम से वाराणसी से दिल्ली ले गया और फिर दिल्ली से गुड़गॉंव (हरियाणा) स्थित मेदान्ता द मेडिसिटी अस्पताल में दिनांक 01-04-2016 को समय 14.40 (मध्यान्ह) पर भर्ती कराया। उक्त अस्पताल में परिवादी की पत्नी दिनांक 30-05-2016 तक कुल 59 - 60 दिन भती रही। इतनी लम्बी अवधि तक भर्ती रहने, उन्हें बेहद मंहगी व इलाज की अच्छी से अच्छी सुविधाऐं प्रदान किए जाने के बाद भी उनकी स्थिति में कोई सुधार नहीं हुआ और उनकी कोमा में बने रहने की स्थिति निरन्तरता में बनी रही और उनकी स्थिति पूर्णतया वैसी ही रही जैसी दिनांक 31-03-2016 को अपेक्स अस्पताल वाराणसी से मेदान्ता द मेडिसिटी अस्पताल गुड़गॉंव ले जाने के समय थी। परिवादी की पत्नी दिनांक 30-03-2016 से हाईपोक्सीक एस्केमीक ब्रेन इन्जरी (Hypoxic escamic brain injury) से पीडि़त है जिसमें परिवादी की पत्नी का मस्तिष्क गम्भीर रूप से क्षतिग्रस्त हो चुका है और वह दिनांक 30-03-2016 से लगातार कोमा की स्थिति में है।
मेदान्ता द मेडिसिटी अस्पताल गुड़गॉंव से छुट्टी कराने के उपरान्त परिवादी अपनी पत्नी को अपने कार्य स्थल सिंगरौली (मध्य प्रदेश) वापस ले आया और उन्हें विभागीय चिकित्सालय सेण्ट्रल हास्पिटल, सिंगरौली में भर्ती कराया है। जहॉं पर परिवादी की पत्नी दिनांक 02-06-2016 से परिवाद योजित किए जाने की तिथि तक अस्पताल में ही भर्ती है, कोमा की स्थिति में है और जीवन के लिए संघर्ष कर रही है।
दिनांक 28-03-2016 को घटित हुई मार्ग दुर्घटना में परिवादी की पत्नी को जो चोटें आईं थीं वह निम्नलिखित थीं :-
Left humures fractured Ulnar fractured Commuted fracture distal 1/3rd right leg Left hand and ankle of right leg fractured मार्ग दुर्घटना उपरोक्त में आई चोटों के कारण जब परिवादी व उसकी घायल पत्नी को नेहरू शाताब्दी चिकित्सालय जयन्त सिंगरौली पहुँचाया गया तो अस्पताल के चिकित्सकों ने पति/पत्नी का एक्स-रे कराया और ऐसे एक्स-रे के आधार पर हम दोंनों की इंजरी रिपोर्ट तैयार की जो कि इस परिवाद पत्र का संलग्नक संख्या-02 है। उपरोक्त इंजरी रिपोर्ट के आधार पर ही चिकित्सकों की यह राय बनी कि परिवादी की पत्नी को जिस तरह की चोटें आईं हैं उनके इलाज के लिए सर्जरी की आवश्यकता होगी। परन्तु उनके चिकित्सालय में अच्छी सर्जरी के पर्याप्त संसाधन उपलब्ध नहीं हैं इसलिए यह बेहतर होगा कि घायल मरीज की सर्जरी किसी अन्य चिकित्सालय में कराई जाए, जहॉं सर्जरी के पर्याप्त संसाधन हों।
उपरोक्त इंजरी रिपोर्ट व चिकित्सकीय सलाह के आधार पर परिवादी व उसकी घायल पत्नी को उपरोक्त अस्पताल से दिनांक 29-03-2016 को सुबह के 09.00 बजे छुट्टी देते हुए अपेक्स अस्पताल वाराणसी के लिए रिफर कर दिया गया। उपरोक्त मार्ग दुर्घटना में आई चोटों के कारण हम पति-पत्नी दर्द के चलते पीड़ा में अवश्य थे परन्तु हमारा उपचार करने वाले चिकित्सकों का यह स्पष्ट मत था कि हमें आई चोटें विशेषकर से परिवादी की पत्नी कोई आई चोटें प्राण घातक नहीं हैं और चिन्ता करने की आवश्यकता नहीं है और सर्जरी के बाद ऐसी चोटें न केवल पूर्णतया ठीक हो जाऐंगी वरन् घायल/पीडि़ता श्रीमती मंजू सिंह शीघ्र ही एक सामान्य जीवन व्यतीत करने लगेंगी।
इसके बाद परिवादी सहित उसकी घायल/पीडि़ता पत्नी को अपेक्स अस्पताल वाराणसी में भर्ती कराया गया, जहॉं उपरोक्त अस्पताल में कार्यरत चिकित्सकों द्वारा घायल/पीडि़ता को त्रुटिपूर्ण चिकित्सकीय सुविधाऐं दिए जाने, इलाज किए जाने में गम्भीर लापरवाही किए जाने, अयोग्य चिकित्सकों से इलाज में सहयोग लिए जाने, चिकित्सालय में विशेषज्ञ चिकित्सकों से सेवाऐं दिए जाने के सम्बन्ध में कोई अनुबन्ध न होने और न ही आकस्मिकता की स्थिति में ऐसे विशेषज्ञ चिकित्सकों को बुलाकर आपातकालीन स्थितियों को सम्भालने में सक्षम होने, चिकित्सालय में अप्रशिक्षित कर्मी होने, आपरेशन थिएटर में आपरेशन की मूलभूत सुविधाऐं न होने, आपरेशन थिएटरमें किसी प्रकार की कोई सुविधा उपलब्ध न होने के कारण तथा उपरोक्त अस्पताल के चिकित्सकों की उपेक्षा, अनावश्यक जल्दबाजी, लापरवाही व अनुचित व्यवसाय प्रक्रिया अपनाए जाने के कारण परिवादी की पत्नी उस स्थिति (कोमा) में पहुँच गई जिसका परिवादी द्वारा इस परिवाद पत्र के पूर्व के प्रस्तरों में अंकन किया गया है।
दिनांक 28-03-2016 को घटित हुई उपरोक्त मार्ग दुर्घटना में आई चोटों का अपेक्स अस्पताल में इलाज कराए जाने और ऐसे इलाज में अपेक्स अस्पताल प्रबन्धन द्वारा दी गई त्रुटिपूर्ण चिकित्सा सेवाओं के कारण परिवादी द्वारा अपेक्स अस्पताल को रूपया 88,129/- का भुगतान किए जाने के अतिरिक्त एयर एम्बुलेंस से वाराणसी से दिल्ली ले जाए जाने में रूपया 4,27,000/-, मेदान्ता द मेडिसिटी के इलाज में रूपया 14,50,907/-, मेदान्ता द मेडिसिटी अस्पताल, गुड़गॉंव से केन्द्रीय अस्पताल सिंगरौली लाने में एम्बुलेंस का किराया रूपया 70,000/- का व्यय किया गया है।
परिवादी के परिवार में कुल 04 सदस्य हैं जिसमें परिवादी, घायल पत्नी, पुत्री जिसका विवाह हो चुका है तथा पुत्र जो बंग्लौर में रहकर अपनी पढ़ाई पूरी कर रहा है। अपनी पत्नी को लेकर परिवादी जब सिंगरौली वापस आया उस समय परिवादी नार्दन कोल लिमिटेड की बल बी0 परियोजना में महाप्रबन्धक के पद पर कार्यरत था और उक्त पद के पदीय कर्तव्यों के निर्वहन में परिवादी पर महत्वपूर्ण प्रशासनिक जिम्मेदारी थी। उपरोक्त के साथ ही परिवादी को एक कोमा में रह रहे मरीज को सम्भाल पाने और उसकी देखभाल कर पाने का कोई जानकारी व अनुभव नहीं था। जिस कारण से मेदान्ता अस्पताल से छुट्टी पाने के उपरान्त परिवादी ने अपनी पत्नी को सीधे केन्द्रीय अस्पताल सिंगरौली में भर्ती कराया।
उक्त केन्द्रीय अस्पताल में परिवादी को चिकित्सकीय देखभाल व चिकित्सकीय परामर्श नि:शुल्क प्राप्त था/है। परन्तु परिवादी की घायल पत्नी को लगातार चिकित्सकीय परामर्श को ध्यान में रखते हुए परिवादी ने माह जून-2016 से 03 नर्सों की सेवाऐं प्राप्त कर रखी हैं। यह तीनों नर्सें 08 - 08 घण्टे की ड्यूटी करती हैं और दूसरी नर्स के आ जाने पर ही पहली नर्स की ड्यूटी समाप्त होती है। उपरोक्त तीनों नर्स को परिवादी द्वारा अपने पास से रूपया 9,000/- मासिक की दर से रूपया 27,000/- वेतन का भुगतान किया जाता है। परिवादी द्वारा उपरोक्त नर्सों को वेतन का ऐसा भुगतान जून-2016 से परिवाद योजित किए जाने की तिथि तक लगातार किया जा रहा है और परिवाद योजित किए जाने की तिथि तक वेतन के मद में रूपया 5,67,000/- का भुगतान किया जा चुका है।
उपरोक्त के अतिरिक्त परिवादी द्वारा लगभग रूपया 50,000/- मासिक की दर से दवाईयों के मद में व्यय किया जा रहा है। उपरोक्त के अतिरिक्त परिवादी नियमित रूप से दिन में एक बार समय निकालकर निश्चित रूप से अपनी घायल/पीडि़ता पत्नी को देखने जाता है जिसमें परिवादी द्वारा लगभग रूपया 3,000/- प्रतिमाह की दर से व्यय किया जा रहा है और परिवाद योजित किए जाने की तिथि तक दवाईयों के मद में लगभग रूपया 10,50,000/- व आने-जाने के मद में लगभग रूपया 63,000/- का व्यय किया जा चुका है।
मेदान्ता द मेडिसिटी अस्पताल गुड़गॉंव से वापस लौटने व अपनी पत्नी श्रीमती मंजू सिंह को केन्द्रीय अस्पताल सिंगरौली में भर्ती कराए जाने के उपरान्त परिवादी ने अपेक्स अस्पताल प्रबन्धन द्वारा त्रुटियुक्त चिकित्सा सुविधा दिए जाने से असंतुष्ट होने के आधार पर मामले की जांच कराए जाने के लिए कम्पनी के उच्चप्रबंधन से अनुरोध किया। परिवादी के अनुरोध पर मुख्य चिकित्सा अधीक्षक नार्दन कोल लिमिटेड ने अपने पत्र दिनांकित 14-09-2016 के माध्यम से 03 चिकित्सकों की एक कमेटी बनाई। 03 चिकित्सकों की इस कमेटी के अध्यक्ष डॉ0 एल0डी0 मिश्रा थे जो इन्स्टीट्यूटी आफ मेडिकल साइंस, बी0एच0यू0 वाराणसी के एनेस्थेसियोलॉजी विभाग के भूतपूर्व प्रोफेसर व विभागाध्यक्ष थे, दूसरे चिकित्सक डॉ0 पंकज कुमार जो एन0एस0सी0 सिंगरौली अस्पताल के एनेस्थेसिया विभाग के विभागाध्यक्ष थे तथा तीसरे चिकित्सक डॉ0 एस0के0 गौतम जो एन0एस0सी0 सिंगरौली अस्पताल के वरिष्ठचिकित्साधिकारी थे।
उक्त जांच कमेटी ने अपेक्स अस्पताल के आपरेशन थिएटर, मरीज के इलाज से सम्बन्धित प्रपत्र तथा अपेक्स अस्पताल से तथाकथित रूप से जुड़े हुए चिकित्सक सहित कुल 05 व्यक्तियों क्रमश: डॉ0 पी0के0 मिश्रा, डॉ0 एस0एस0 पटेल, डॉ0 सौरभ, डॉ0 अमित भाष्कर व एक अन्य जे0पी0 उपाध्याय से पूछताछ की और उपरोक्त के आधार पर दिनांक 22-09-2016 को अपनी जांच रिपोर्ट तैयार कर ऐसी जांच रिपोर्ट मुख्य चिकित्सा अधीक्षक को सौंप दी। जो जांच रिपोर्ट मुख्य चिकित्सा अधीक्षक के माध्यम से परिवादी को दिनांक 16-08-2017 को प्राप्त हुई।
उपरोक्त जांच रिपोर्ट के अवलोकन से परिवादी को इस तथ्य की जानकारी हुई कि अपेक्स अस्पताल वाराणसी के आपरेशन थिएटर में आपरेशन की मूलभूत सुविधाऐं उपलब्ध नहीं थीं। इसी के साथ ही अपेक्स अस्पताल द्वारा एनेस्थेसिया के सम्बन्ध में जिस चिकित्सक डॉ0 सौरभ उर्फ डॉ0 सौरभ सुमन की सेवाऐं ली जा रही थीं वह अपने क्षेत्र में एक प्रशिक्षु चिकित्सक थे और ऐसे चिकित्सक के पास चिकित्सा शिक्षा से जुड़ी हुई अर्हता भले ही रही हो परन्तु योग्यता व अनुभव बिल्कुल नहीं था जिसका परिणाम यह था कि परिवादी की पत्नी आपरेशन थिएटर में चिकित्सकीय लापरवाही के परिणाम स्वरूप कोमा में चली गई और पिछले लगभग 02 वर्षों से कोमा की स्थिति में ही है और भविष्य में कोमा की स्थिति से सामान्य जीवन में वापस लौटेगी या नहीं अथवा कब तक कोमा की स्थिति में बनी रहेगी, इसका कोई भी स्पष्ट उत्तर चिकित्सा क्षेत्र में कार्यरत चिकित्सकों के पास आज भी नहीं है।
विपक्षी अपेक्स अस्पताल द्वारा की गई चिकित्सकीय लापरवाही के परिणाम स्वरूप परिवादी की पत्नी के कोमा में चले जाने व उसके जीवन पर संकट उत्पन्न हो जाने के आधार पर परिवादी द्वारा उपरोक्त चिकित्सकीय संस्थान अपेक्स अस्पताल के विरूद्ध यह परिवाद संस्थित किया जा रहा है। विपक्षी चिकित्सकीय संस्थानद्वारा गम्भीर रूप से त्रुटिपूर्ण सेवाऐं दिए जाने के कारण जहॉं परिवादी की पत्नी के कोमा में चले जाने से उसके बहुमूल्य जीवन पर गम्भीर संकट उत्पन्न हो गया है वहीं दूसरी तरफ विपक्षी द्वारा गम्भीर रूप से त्रुटिपूर्ण सेवाऐं दिए जाने के कारण परिवादी को अपनी पत्नी के कोमा में चले जाने से गम्भीर मानसिक पीड़ा हो रही है, शारीरिक उत्पीड़न का सामना करना पड़ रहा है, वहीं दूसरी तरफ अनावश्यक आर्थिक व्यय भार भी वहन करना पड़ रहा है। जिसके लिए पूरी तरह से विपक्षी चिकित्सकीय संस्थान अपेक्स अस्पताल व इसके चिकित्सक उत्तरदायी है और विपक्षी चिकित्सकीय संस्थान अपेक्स अस्पताल का आचरणपरिवादी को दी जाने वाली सेवाओं में त्रुटि के समकक्ष है।
विपक्षी चिकित्सकीय संस्थान अपेक्स अस्पताल के लिए न केवल कोमा की स्थिति में जीवित मरीज श्रीमती मंजू सिंह उपभोक्ता की श्रेणी में आती है वरन् परिवादी स्वयं भी विपक्षी चिकित्सकीय संस्थान अपेक्स अस्पताल के लिए उपभोक्ता की श्रेणी में आता है क्योंकि विपक्षी चिकित्सकीय संस्थान को निर्धारित शुल्क का भुगतान करके अपनी पत्नी के इलाज के सम्बन्ध में परिवादी द्वारा चिकित्सकीय सुविधाऐं प्राप्त की गई थीं।
यह कि जिस समयावधि दिनांक 29-03-2016 से दिनांक 31-03-2016 के बीच परिवादी को उसकी पत्नी के इलाज के सम्बन्ध में विपक्षी चिकित्सकीय संस्थान से त्रुटियुक्त चिकित्सीय सेवाऐं प्राप्त हुईं और जिन त्रुटियुक्त चिकित्सकीय सेवाओं के कारण परिवादी की पत्नी दिनांक 30-03-2016 से लगातार कोमा में चल रही हैं और अपने जीवन के लिए संघर्ष कर रही हैं उस समयावधि में विपक्षी चिकित्सकीय संस्थान व इसके प्रमुख चिकित्सक डॉ0 एस0के0 सिंह को ओरियण्टल इंश्योरेंस कं0लि0 से Error and Ommision Medical Establishment नामक बीमा पालिसी से बीमा पालिसी सं0-222501/48/2016/188, वैधता दिनांक 26-04-2015 से दिनांक 25-04-2016 के मध्य बीमा आवरण प्राप्त था। विपक्षी चिकित्सकीय संस्थान को उपरोक्त बीमा पालिसी शाखा कार्यालय सं0-01, हथुवा मार्केट, पहली मंजिल, चेतगंज, लहुरावीर, जिला-वाराणसी के शाखा प्रबन्धक द्वारा दिनांक 22-04-2015 को जारी किया गया था।
यह कि मुझ परिवार की पत्नी श्रीमती मंजू सिंह को तथा मुझ परिवादी को विपक्षी चिकित्सकीय संस्थान द्वारा त्रुटियुक्त चिकित्सकीय सेवायें दिये जाने का तथ्य स्थापित हो जाने के उपरान्त त्रुटियुक्त उपभोक्ता सेवाओं के सम्बंध में माननीय राज्य आयोग द्वारा विपक्षी चिकित्सकीय संस्थान पर प्रतिकर की धनराशि के भुगतानका जो दायित्व आरोपित किया जायेगा। प्रतिकर की नियत की गयी धनराशि के भुगतान सम्बन्धी उस दायित्व के लिये विपक्षी चिकित्सकीय संस्थान के स्थान पर बीमा कम्पनी को उत्तरदायी ठहराया जाना न्यायहित में प्रार्थनीय है।
परिवादी द्वारा निम्न अनुतोष दिलाए जाने की प्रार्थना की गई है :-
विपक्षी चिकित्सकीय संस्थान व ऐसे चिकित्सकीय संस्थान में कार्यरत चिकित्सक जो अपने कर्तव्यों के अनुपालन में घोर उपेक्षा,लापरवाही, त्रुटिपूर्ण चिकित्सकीय सेवाऐं दिए जाने व अनुचित व्यवसायिक प्रक्रिया अपनाए जाने के दोषी है। ऐसे चिकित्सकीय संस्थान व ऐसे चिकित्सकीय संस्थान में कार्यरत चिकित्सकों से परिवादी को कोमा की स्थिति में अपना जीवन व्यतीत कर रही और अपने जीवन के लिए संघर्ष कर रही श्रीमती मंजू सिंह की चिकित्सकीय देखभाल सुनिश्चित किए जाने के लिए 70 वर्ष की औसत आयु स्वीकार करते हुए श्रीमती मंजू सिंह के लिए 15 वर्षों का व्यय रूपया 50,000/- मासिक मानते हुए (जिसमें नर्सों का वेतन, दवाईयों का व्यय, चिकित्सा व अन्य यात्रा व्यय सम्मिलित है) रूपया 90,00,000/- (रूपया नब्बे लाख) प्रतिकर के रूप में दिलाए जाने का आदेश दिया जाना न्यायहित में प्रार्थनीय है।
ख. यह कि विपक्षी चिकित्सकीय संस्थान तथा ऐसे संस्थान में कार्यरत चिकित्सकों द्वारा की गई चिकित्सकीय लापरवाही के कारण परिवादी को अपनी पत्नी के प्रेम, स्नेह व सहचर्य से वंचित हो जाना पड़ा है। इसी प्रकार से परिवादी को दोनों सन्तानों को भी अपनी मॉं के प्रेम व स्नेह से तथा अपनी मॉं से मिलने वाली नैसर्गिक देखभाल से वंचित होना पड़ा है और हम सभी को लगातार गम्भीर मानसिक दु:ख एवं कष्ट पहुँच रहा है जिसके लिए परिवादी समेत उसकी दोनों संतानों को रूपया 3,00,000/- प्रति व्यक्ति के आधार पर रूपया 9,00,000/- प्रतिकर विपक्षी चिकित्सकीय संस्थान से दिलाए जाने का आदेश किया जाना न्यायहित में प्रार्थनीय है।
ग. यह कि विपक्षी चिकित्सकीय संस्थान तथा ऐसे संस्थान में कार्यरत चिकित्सकों द्वारा की गई चिकित्सकीय लापरवाही के कारण परिवादी को यह परिवाद संस्थित किए जाने के लिए विवश होना पड़ा है और परिवाद योजित किए जाने से पूर्व ऐसे परिवाद की तैयारियों व अधिवक्ता फीस आदि के सम्बन्ध में परिवादी को जो धनराशि व्यय करनी पड़ी है उस सम्ब्न्ध में रूपया 1,00,000/- का भुगतान विपक्षी चिकित्सकीय संस्थान से दिलाए जाने का आदेश किया जाना न्यायहित में प्रार्थनीय है।
ग(अ). यह परिवादी के पक्ष में नियत की गई प्रतिकर की समस्त धनराशि के भुगतान का दायित्व विपक्षी चिकित्सकीय संस्थान के स्थान पर विपक्षी बीमा कम्पनी के विरूद्ध आरोपित किया जाना न्यायहित में प्रार्थनीय है।
घ. यह कि अन्य कोई अनुतोष जिसे माननीय आयोग प्रस्तुत परिवाद के परिवादी को विपक्षी चिकित्सकीय संस्थान व ऐसे चिकित्सकीयसंस्थान में कार्यरत चिकित्सकों से दिलाया जाना उचित समझती हो तो ऐसा अनुतोष भी परिवादी को विपक्षी चिकित्सकीय संस्थान व ऐसे चिकित्सकीयसंस्थान में कार्यरत चिकित्सकों से दिलाए जाने का आदेश पारित किया जाना न्यायहित में प्रार्थनीय है।
विपक्षी अपेक्स अस्पताल द्वारा अपना लिखित कथन प्रस्तुत किया गया, जिसमें कहा गया है कि परिवादी द्वारा गलत कपोल कल्पित तत्यों के आधार पर उपरोक्त मुकदमा माननीय न्यायालय में दाखिल किया गया है, जिसमें रंच मात्र भी सत्यता नहीं है, जो हर प्रकारसे खारिज होने योग्य है। उपरोक्त वाद परिवादी द्वारा माननीय न्यायालय में दाखिल कर विपक्षी की छवि धूमिल करने की नियत से वह विपक्षी से नाजायज धनराशि ऐंठने की गरज से दाखिल किया गया है जो सरासर गलत है।
परिवादी का सर्व प्रथम वाद कारण दिनांक 28-03-2016 को उत्पन्न हुआ जबकि परिवादी व उसकी पत्नी का एक्सीडेण्ट हुआ, जिसके सम्बन्ध में अपराध सं0 177 सन् 2016 सरकार बनाम अज्ञात के नाम से दर्ज किया गया है और परिवादी का जिस गाड़ी से एक्सीडेण्ट हुआ, उसी के स्वामी व वाहन के इंश्योरेंस कम्पनी के ऊपर क्लेम दाखिल करने का अधिकार है। उक्त एफ0आई0आर0 में जिस गाड़ी से एक्सीडेण्ट हुआ उसके ऊपर व ड्राइवर के ऊपर व वाहन स्वामी के विरूद्ध क्लेम दाखिल नहीं किया गया है एवं न ही इस वाद पत्र में वाहन स्वामी को पक्षकार ही बनाया गया है। अत: परिवादी का वाद खारिज होने योग्य है।
परिवादी द्वारा विपक्षी के ऊपर जो आरोप लगाया गया है वह सरासर गलत है। विपक्षी का हास्पिटल एक ख्यातिलब्ध हास्पिटल है। भारत सरकार व उत्तर प्रदेश सरकार द्वारा जांच पड़ताल कराने के उपरानत सभी सुविधाऐं पाते हुए सुपर मल्टी स्पेशलिटी हास्पिटल का दर्जा दियागयाहै और एन0सी0एल0 हास्पिटल सिंगरौली, मध्य प्रदेश के डॉक्टर व उच्च अधिकारियों द्वारा जांच करने के उपरान्त ही विपक्षी के हास्पिटल को एन0सी0एल0 के मरीजों का इलाज करने के लिए अधिकृत किया गया है, जिसके तहत प्राथमिक उपचार परिवादी की पत्नी का करने के उपरान्त अत्यधिक गम्भीर स्थिति होने के कारण विपक्षी के हास्पिटल में इलाज हेतु रेफर किया गया था और विपक्षी द्वारा अथक मेहनत व प्रयास व सावधानीपूर्वक इलाज किए जाने के बाबजूद परिवादी की पत्नी अत्यधिक गम्भीर स्थिति होने के कारण वह आपरेशन के दौरान् कोमा में चली गई। ऐसी स्थिति एकाध मरीज में हो जाती है जैसा कि परिवादी की पत्नी के आपरेशन के दौरान हुआ।
परिवादी का यह कथन सरासर गलत है कि उसकी पत्नी का आपरेशन किए जाने के पूर्व उससे विपक्षी अस्पताल के डाक्टरों द्वारा कोई सहमति नहीं ली गई थी। जबकि परिवादी की पत्नी का आपरेशन डी0एन0 सिंह की अनुमति से किया गया, जो कि परिवादी के सगे रिश्तेदार हैं। आपरेशन के समय परिवादी की पत्नी ठीक थी परन्तु होश में नहीं आयी जिसकी जिम्मेदारी विपक्षी की नहीं है। विपक्षी के हास्पिटल में हर प्रकार की मशीन व सुविधाऐं उपलब्ध हैं जो किसी भी समय जांच किया जा सकता है। हास्पिटल में सभी प्रकार के चिकित्सीय उपकरण उपलब्ध हैं।
आपरेशन के पूर्व समस्त प्रकार की जाचं पड़ताल करने के उपरान्त ही परिवादी की पत्नी को इलाज दिया गया और आपरेशन के दौरान मरीज कोमामें चला गया इसकी जिम्मेदारी डॉक्टर की नहीं है। कोई भी डॉक्टर किसी भी मरीज के साथ जानबूझकर लापरवाही नहीं करता है। इसके विरूद्ध कही गयी बातें कपोल कल्पित व मनगढ़न्त तरीके से विपक्षी के हास्पिटल की छवि धूमिल करने के लिए अंकित की गयी हैं।
विपक्षी के हास्पिटल में अत्याधुनिक तरीके का आपरेशन थिएटर है और प्रत्येक ओ0टी0 व रूप में ऑक्सीजन की पाइप लगी हुई है, जिससे मरीज को ऑक्सीजन आवश्यकतानुसार दिया जाता है। विपक्षी के हास्पिटल पर आज तक किसी भी व्यक्ति ने, परिवादी जैसा आरोप जो कि सरासर गलत है, नहीं लगाया है।
मरीज की वास्तविक स्थिति के बारे में मरीज के तिमारदार डी0एन0 सिंह को बताया जाता रहा और वह स्वयं भी हमेशा मरीज को देखा करते थे और हर स्थिति में उनको मरीज के बारे में अवगत कराया जाता रहा है एवं श्री डी0एन0 सिंह द्वारा स्वेच्छा से आपरेशन सहमति पत्र पर हस्ताक्षर किए गए थे।
मरीज का इलाज एपेक्स हास्पिटल में किया जा रहा था परन्तु मरीज की स्थिति में कोई सुधार नही हो रहा था जिस पर मरीज के तिमारदार के निवेदन पर मरीज को डिस्चार्ज करके अन्य इलाज कराने हेतु ले जाने हेतु रेफरल पेपर बनाकर दिया गया जो कि पत्रावली में संलग्न है।
विपक्षी द्वारा इलाज से सम्बन्धित समस्त अभिलेख इस मुकदमे में दाखिल किया जा रहा है जिसके देखने से स्पष्ट है कि मरीज के इलाज में कोई लापरवाही नहीं हुई है। परिवादी द्वारा मात्र विपक्षी को तंग व परेशन करने के लिए और अपनी पत्नी के ठीक न होने के कारण खीज उतारने के लिए यह मुकदमा दाखिल किया गया है, जो हर प्रकार से खारिज होने योग्य है।
विपक्षी का हास्पिटल दी ओरियण्टल इंश्योरेंस कं0लि0, 28, गिरी नगर, वीरदोपुर, वाराणसी उ0प्र0 द्वारा इंश्योर्ड है। कोई भी क्लेम यदि बनता है तो उसकी जिम्मेदारी इंश्योरेंस कम्पनी की होती है।
परिवादी द्वारा इंश्योरेंस कम्पनी को पक्षकार नहीं बनाया गया है। अत: पक्षकार न बनाए जाने के कारण उपरोक्त मुकदमा खारिज होने योग्य है। हास्पिटल में किसी भी मरीज के साथ अनहोनी होने पर इंश्योरेंस कम्पनी जिम्मेदार है जो कि उक्त मुकदमा में एक आवश्यक पक्षकार है।
उपरोक्त मुकदमा माननीय न्यायालय को सुनने का क्षेत्राधिकार नहीं है, जो हर प्रकार से खारिज होने योग्य है।
विपक्षी अस्पताल द्वारा परिवादी की पत्नी के इलाज में किसी प्रकार प्रकार की लापरवाही नहीं बरती गई है और न ही किसी प्रकार की सेवा में कमी की गई है। विपक्षी अस्पताल के द्वारा सर्वमान्य चिकित्सा पद्धति के अनुसार इलाज किया गया है। मा0 सर्वोच्च न्यायालय द्वारा प्रतिपादित गाइडलाइन्स के अनुसार इलाज किया गया है उसमें किसी प्रकार की कोताही नहीं बरती गई है।
वर्तमान मामले में चिकित्सीय उपेक्षा और सेवा में कमी का आधार परिवादी ने लिया है। जब भी कोई मरीज किसी डॉक्टर को दिखाने जाता है तब उनके बीच एक प्रत्यक्ष सम्बन्ध स्थापित होता है और यह चिकित्सा क्षेत्र में अत्यधिक महत्वपूर्ण कदम है और इसी विश्वास के कारण डॉक्टर का उत्तरदायित्व होता है कि वह रोगी के प्रति अपने दायित्व का निर्वहन सफलतापूर्वक करे। इस सम्बन्ध में निम्नलिखित लेख महत्वपूर्ण है जिसे यहॉं उद्धृत किया जा रहा है :-
First of all we have to see the doctor - patient relationship (DPR). This relationship is very important for all types of treatment of a patient by a doctor.
"Medicine is an art whose magic and creative ability have long been recognized as residing in the interpersonal aspects of patient-physician relationship."
Hall et al.,1981 A doctor-patient relationship (DPR) is considered to be the core element in the ethical principles of medicine. DPR is usually developed when a physician tends to a patient's medical needs via check-up, diagnosis, and treatment in an agreeable manner. Due to the relationship, the doctor owes a responsibility to the patient to proceed toward the ailment or conclude the relationship successfully. In particular, it is essential that primary care physicians develop a satisfactory DPR in order to deliver prime health care to patients.
The physician-patient relationship is a foundation of clinical care. Physician-patient relationships can have profound positive and negative implications on clinical care. Ultimately, the overarching goal of the physician-patient relationship is to improve patient health outcomes and their medical care. Stronger physician-patient relationships are correlated with improved patient outcomes. As the relationship between physicians and patients becomes more important, it is essential to understand the factors that influence this relationship.
Frameworks for Physician-Patient Relationships Throughout history there has been much debate regarding the "ideal" physician-patient relationship. In 1992, Ezekiel and Linda Emanuel proposed four models for the physician-patient relationship: the paternalistic model, the interpretive model, the deliberative model, and the informative model. These models differ based on their understanding of four key principles: the goals of physician-patient interactions, the physician's obligations, the role of patient values, and the concept of patient autonomy.
Factors that Influence the Physician-Patient Relationship Although there are several factors that influence physician-patient relationships, the dynamic shared and sense of trust between physicians and patients are two critical components to their overall relationship.
Dynamic Between Physicians and Patients The dynamic between physicians and patients refers to the communication patterns and the extent to which decision making is shared between both parties. Effective physician-patient communication is an integral part of clinical practice and serves as the keystone of physician-patient relationships. Studies have shown the approach taken by physicians to communicate information is equally important as the actual information that is being communicated. This type of communication incorporates both verbal and nonverbal interactionsbetween physicians and patients.iEffective communication has been shown to influence a wide array of outcomesincluding: emotional health, symptoms resolution, function, pain control, and physiologic measures such as blood pressure levels. When miscommunication occurs, it can have severe negative implications in clinical caresuch as impeding patient understanding, expectations of treatment, treatment planning, decreasing patient satisfaction of medical care, and reducing levels of patient hopefulness.
In addition to having effective communication, it is important that medical decisions stem from a collaborative process between physicians and patients. Decision makingis a process in which patients should be involved from the very beginning, and the result is a decision which reflects the physician's medical knowledge as well as the patient's values and beliefs.ivCollaborative communication and decision making have been correlated with greater patient satisfaction and loyalty. Working from a collaborative framework along with effective physician-patient communication can also strengthen a physician's ability to utilize a personalized health care model through patient empowerment.v Trust Between Physician and Patients "....'patients must be able to trust doctors with their lives and health,' and that maintaining trust is one core guidance for physicians..."
Birkhäuer et al, 2017 Trust is a fundamental characteristic of the physician-patient relationship. Patients must trust that their physicians will work in their best interests to achieve optimal health outcomes. Patients' trust in their physicians has been demonstrated to be more important than treatment satisfactionin predictions of patient adherence to recommendations and their overall satisfaction with care.iStudies have also shown that trust is additionally a strong predictor of a patient continuing with their provider.iiTrust extends to many different aspects of the physician-relationships including, but not limited to: physicians' willingness to listen to patients, patients' believing that physicians value patient autonomy and ability to make informed decisions, and patients feeling comfortable enough to express and engage in dialogue related to their health concerns.
Physician-Patient Relationships Influence on the Future of Healthcare The idea of viewing physician-patient relationships as a core element of quality health care is not something new, however understanding and assessing the factors that influence this relationship is just beginning. Effective physician-patient communication has been shown to positively influence health outcomes by increasing patient satisfaction, leading to greater patient understanding of health problems and treatments available, contributing to better adherence to treatment plans, and providing support and reassurance to patients. Collaborative decision making enables physicians and patients to work as partners in order to achieve a mutual health goal. Trust within all areas of the physician-patient relationship is a critical factor that influences communication between both parties. As health care transforms into a more personalized and patient-centered model, the physician-patient relationship will significantly shape health outcomes. The personalized health care model encourages collaboration among physicians and patients in order to create shared health goals and the cultivation of a health plan to address identified problems. By understanding the factors that influence patient-physician relationships, in the future, health care providers will be able to address some of the barriers that prevent the adoption of more personalized approaches to health care.
डॉक्टर का प्रारम्भिक दायित्व है कि वह अपने रोगी के लिए बढि़या से बढि़या उत्तम प्रकृति का इलाज प्रदान करे और एक योग्य तथा कुशल डॉक्टर इस दायित्व का निर्वहन भलीभांति करता है। यह सम्बन्ध अत्यधिक महत्व का है और यदि डॉक्टर यह पाता है कि वह एक मरीज के रोग का निदान प्रभावकारी ढंग से नहीं कर सकता है तब वह उसे किसी विशेषज्ञ संगठन या अच्छी सुविधा देने वाले स्वास्थ्य केन्द्र को सन्दर्भित करेगा। अपने कार्य के दौरान् डॉक्टर का यह भी दायित्व है कि वह विशेषज्ञ स्वास्थ्य सेवाऐं देने वाली एजेन्सी, डॉक्टर या संगठन से सम्पर्क कर सहयोग प्राप्त करे। डॉक्टर के 07 निम्नलिखित उत्तरदायित्व होते हैं जिनको निम्न लेख के माध्यम से स्पष्ट किया गया है :-
The primary responsibility of a doctor is to ensure they can provide their patients with the best level of care. A talented doctor can perform these tasks efficiently while practising a range of soft skills, such as effective communication. When considering a career in medicine, it may be helpful to know the basic duties a doctor performs daily.
What are a doctor's responsibilities?
There are seven key tasks that make up a doctor's responsibilities that most perform as part of their daily working routine. The duties of a doctor may vary depending on where they work, the type of doctor they are and the conditions of the patients they treat that day. While there may be some differences in a doctor's primary tasks, outlined below are seven common duties that doctors within any speciality can typically perform. These include the following:
Diagnosing any illness and other conditions A Dr is qualified to diagnose a range of illness, injuries, diseases or pains that a patient may be experiencing. The made in several tests on a patient before they reach their final diagnosis to ensure their decision is accurate. They also want to ensure that they can rule other illnesses out the time it takes for a Dr to make a diagnosis depends on what the ailment is and the severity of symptoms that the patient showing. For injuries, doctors can usually make an accurate diagnosis straightaway, whereas diseases or chronic illness may take a few weeks to Dr to detect.
Planning and conducting a patient's course of treatment following a diagnosis, a doctor may then plan and prepare a course of treatment for the patient. Individuals in this profession use their technical knowledge and medical research skills to find the quickest and most effective form of treatment. This process may include finding suitable medication, providing care for any external wounds or referring the patient to be more specialised doctor.
A doctor typically discusses their recommended treatment course with the patient to ensure that the individual is happy to proceed. If the doctor is treating a child, they may require the parents permission to conduct the treatment plan.
Any stream follow-up care for patients if necessary if a doctor feels they cannot treat a patient effectively, they may refer the patient to a specialist organisation or healthcare provider. This may occur if a patient is experiencing problems with their teeth, eyes or mental health because a dentist, optometrist or psychiatrist is more likely to find the root of the issue.
The doctor may also ask the patient to make a follow-up appointment with them for a variety of reasons. The reasons may be to check the progress of symptoms, run further tests and administer higher or lower doses of medication. They may also ask patients to arrange a further appointment to discuss any blood test or laboratory results. For the Bulls, the doctor may want to redress bandages and thoroughly cleanse the cut to prevent infection.
Consulting with other healthcare professionals during their working day, a doctor may consult with other healthcare professionals that work at their organisation or a specialist unit. A doctor may ask a nurse practitioner to assist them with running tests or consult with a fellow doctor to gain a second expert opinion on the patient's case. If they wish to have a patient admitted to hospital they may communicate with hospital staff via telephone to arrange an appointment on behalf of the patient.
If a patient is experiencing symptoms that are associated with a specific area in medicine, a doctor may contact a specialist unit to consult with a specialist Dr. For example if a patient is complaining of frequent chest pains, a doctor may consult with cardiologist to discuss a suitable treatment plan.
Prescribing medication a doctor is also responsible for prescribing the most effective medicine for a patient's symptoms. They may write a prescription for the patient to take with them to a pharmacy or contact the pharmacy directly. Doctors can prescribe medication to either cure illness or offer relief from symptoms. This medication can take various forms, including tablets, gels, creams and liquids.
To ensure the prescribed medication is effective, the doctor may ask the patient to schedule a follow-up appointment. If the medicine has made no improvements to the patient's illness, the doctor can then consider other medications or alternative forms of treatment. It is crucial that a doctor is aware of the patient's allergies or intolerances before prescribing medication.
Staying updated with medical research a skilled doctor requires a wealth of technical knowledge to identify and treat ailments. As technological and medicinal research progresses, it is responsible to offer doctor to show that they are up to date on the latest advancements in the healthcare industry. This includes researching new diseases, understanding the risks and benefits of new medications and learning how to conduct new procedures.
The primary responsibility of a doctor is to ensure they can provide their patients with the best level of care. A talented doctor can perform these tasks efficiently while practising a range of soft skills, such as effective communication. When considering a career in medicine, it may be helpful to know the basic duties a doctor performs daily.
What are a doctor's responsibilities?
There are seven key tasks that make up a doctor's responsibilities that most perform as part of their daily working routine. The duties of a doctor may vary depending on where they work, the type of doctor they are and the conditions of the patients they treat that day. While there may be some differences in a doctor's primary tasks, outlined below are seven common duties that doctors within any speciality can typically perform. These include the following:
Diagnosing any illness and other conditions A Dr is qualified to diagnose a range of illness, injuries, diseases or pains that a patient may be experiencing. The made in several tests on a patient before they reach their final diagnosis to ensure their decision is accurate. They also want to ensure that they can rule other illnesses out the time it takes for a Dr to make a diagnosis depends on what the ailment is and the severity of symptoms that the patient showing. For injuries, doctors can usually make an accurate diagnosis straightaway, whereas diseases or chronic illness may take a few weeks to Dr to detect.
Planning and conducting a patient's course of treatment following a diagnosis, a doctor may then plan and prepare a course of treatment for the patient. Individuals in this profession use their technical knowledge and medical research skills to find the quickest and most effective form of treatment. This process may include finding suitable medication, providing care for any external wounds or referring the patient to be more specialised doctor.
A doctor typically discusses their recommended treatment course with the patient to ensure that the individual is happy to proceed. If the doctor is treating a child, they may require the parents permission to conduct the treatment plan.
Any stream follow-up care for patients if necessary if a doctor feels they cannot treat a patient effectively, they may refer the patient to a specialist organisation or healthcare provider. This may occur if a patient is experiencing problems with their teeth, eyes or mental health because a dentist, optometrist or psychiatrist is more likely to find the root of the issue.
The doctor may also ask the patient to make a follow-up appointment with them for a variety of reasons. The reasons may be to check the progress of symptoms, run further tests and administer higher or lower doses of medication. They may also ask patients to arrange a further appointment to discuss any blood test or laboratory results. For the Bulls, the doctor may want to redress bandages and thoroughly cleanse the cut to prevent infection.
Consulting with other healthcare professionals during their working day, a doctor may consult with other healthcare professionals that work at their organisation or a specialist unit. A doctor may ask a nurse practitioner to assist them with running tests or consult with a fellow doctor to gain a second expert opinion on the patient's case. If they wish to have a patient admitted to hospital they may communicate with hospital staff via telephone to arrange an appointment on behalf of the patient.
If a patient is experiencing symptoms that are associated with a specific area in medicine, a doctor may contact a specialist unit to consult with a specialist Dr. For example if a patient is complaining of frequent chest pains, a doctor may consult with cardiologist to discuss a suitable treatment plan.
Prescribing medication A doctor is also responsible for prescribing the most effective medicine for a patient's symptoms. They may write a prescription for the patient to take with them to a pharmacy or contact the pharmacy directly. Doctors can prescribe medication to either cure illness or offer relief from symptoms. This medication can take various forms, including tablets, gels, creams and liquids.
To ensure the prescribed medication is effective, the doctor may ask the patient to schedule a follow-up appointment. If the medicine has made no improvements to the patient's illness, the doctor can then consider other medications or alternative forms of treatment. It is crucial that a doctor is aware of the patient's allergies or intolerances before prescribing medication.
Staying updated with medical research a skilled doctor requires a wealth of technical knowledge to identify and treat ailments. As technological and medicinal research progresses, it is responsible to offer doctor to show that they are up to date on the latest advancements in the healthcare industry. This includes researching new diseases, understanding the risks and benefits of new medications and learning how to conduct new procedures.
कोई भी छात्र चिकित्सा जगत के क्षेत्र में एम0बी0बी0एस0 उत्तीर्ण करने के पश्चात् जब इस पेशे में आता है तब इस चिकित्सकीय प्रक्रिया में शामिल होने से पहले उसे एक शपथ लेनी होती है जिसके अन्तर्गत वह मानवता के लिए अपनी सेवाऐं और अपना जीवन अर्पित करता है और कभी भी भय से न डरते हुए मानवता के हित के लिए अपने ज्ञान का उपयोग करता है और उसके लिए उसके रोगी का स्वास्थ्य उसकी पहली प्राथमिकता होती है। साथ ही साथ वह इण्डियन मेडिकल काउन्सिल (प्रोफेशनल कण्डक्ट ऐटिकेट और ऐथिक्स) रेगूलेशन्स 2002 का अनुपालन करता है, जैसा कि निम्न लेख से स्पष्ट होता है :-
Now let us see the oath taken be a doctor before entering the nobel profession of the Medical World. The tradition in medical school includes taking the Hippocratic Oath usually at graduation. The purpose of this review is to examine what that oath has been, what forms it currently has, and the implications for physicians in today's healthcare environment. The changes in health economics affect physicians as they try to follow the oath's allegiance to the individual patient's needs. At times, this goal conflicts with the perspective of the financial world's controls of insurance companies and medical groups and institutions. This difference of the physicians' ethical perspectives from the business leaders regarding the philosophy of the value of the individual's health and life may be related to some aspect of physician burnout.
Many populations in the world know of the Hippocratic Oath for physicians as they begin the journey to care for patients. In this current era of medicine the frequency of students' taking the oath has increased to nearly every one compared to the early twentieth century; however, few medical students and physicians actually know that the translations of the ancient words have become less complete, as well as quite varied from the classical translations. With more and more medical students taking an oath, the content actually has been simultaneously thinned. Certainly, the part addressed to faith in the Greek deities, in whom the ancient physicians believed, does not exactly apply for different locations and religions. It does honor the history of medicine and the bond with principles of the selfless tradition of healing. Now the act of saying the oath with peers has been viewed as a process of getting the diploma from medical school rather than a devoted allegiance to the purpose of medical education, namely, the best care of each patient by a competent physician. A true physician focuses his or her care of each patient not only on the use of skilful and current techniques but also on the recognition of the unique needs and welfare of the patient. This professional devotion of the compassionate physician to the patient may be eroded as the concept of the oath faces challenges from the increasing demands and restrictions by corporate entities. The years of education and training lead to the agreement with a code of ethics in medicine that emphasizes behavior to earn the trust of patients. Some of the burnout of physicians may indicate the loss of autonomy and the need to free physicians to return to the core content of the oath, i.e., to uphold the highest standards of care for the safety and health of each patient.
As per guidelines of MCI, Every member should get it framed in his or her office it should never be violated in its letter and spirit.
"I solemnly pledge myself to consecrate my life to service of humanity.
Even under threat, I will not use my medical knowledge contrary to the laws of Humanity.
I will maintain the utmost respect for human life from the time of conception.
I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient.
I will practice my profession with conscience and dignity.
The health of my patient will be my first consideration.
I will respect the secrets which are confined in me.
I will give to my teachers the respect and gratitude which is their due.
I will maintain by all means in my power, the honour and noble traditions of medical profession.
I will treat my colleagues with all respect and dignity.
I shall abide by the code of medical ethics as enunciated in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002.
I make these promises solemnly, freely and upon my honour."
Whether this oath has been complied with properly by the doctor. We know that the human body is a very complex body. The doctor spent years to study the course of MBBS/MD/MS and any other specialisedfields . Despite of all the facts they should be cautious during treatment of a patient because it is the patient who paid them for their livelihood. It is the utmost and noble duty of a doctor to adhere with the oath taken by him.
So it is very important to maintain trust between the patient and the concerned Doctor. The doctors should also adhere to their oath taken by them when entering into this noble profession.
प्रस्तुत मामले में परिवादी अपनी पत्नी के साथ दिनांक 28-03-2016 को डेहरी से गोरबी की तरफ आ रहा था। लगभग 8 बजे रात्रि बंजारा होटल के आगे एक मोड़ पर यह वाहन एक ट्रक से टकरा गया जिसके फलस्वरूप कार में बैठे लोगों को चोटें आयीं। दुर्घटना के सम्बन्ध में प्राथमिकी अंकित कराई गई। परिवादी और उसकी पत्नी को पहले निकटवर्ती चिकित्सालय नेहरू शताब्दीचिकित्सालय जयन्त (सिंगरौली) ले जाया गया जहॉं पर प्राथमिक उपचार देने के पश्चात् उन्हें आगे की चिकित्सा के लिए वाराणसी सन्दर्भित किया गया।
दुर्घटना के दूसरे दिन सायं 5 बजे परिवादी और उसकी पत्नी को अपेक्स हास्पिटल वाराणसी में भर्ती कराया गया जहॉं पर दोनों की चोटों की जांच की गई और यह पाया गया कि परिवादी की पत्नी को जो चोट आयी है उसके लिए शल्य चिकित्सा आवश्यक है। दिनांक 30-03-2016 को परिवादी की पत्नी की स्थिति अस्थिर थी और वह शल्य चिकित्सा के योग्य नहीं थी किन्तु इसके बाबजूद अपेक्स अस्पताल के चिकित्सक डॉक्टर एस0के0 सिंह के पुत्र डॉक्टर स्वरूप एस0 पटेल, अस्थि रोग विशेषज्ञ ने परिवादी को बिना बताए परिवादी की पत्नी को आपरेशन थिएटर में भेज दिया जहॉं पर डॉ0 सौरभ ने एनेस्थेसिया दिया और एनेस्थेसिया देते ही परिवादी की पत्नी पर उसका विपरीत प्रभाव हुआ और वह मूर्छित होकर कोमा में चली गई। परिवाद प्रस्तुत किए जाने के दिनांक तक परिवादी की पत्नी कोमा में ही है और अपेक्स हास्पिटल इस सम्बन्ध में परिवादी की पत्नी को होश में लाने के लिए किसी भी कार्यवाही को करने में अक्षम रहा जो उसकी अनुशानहीनता और लापरवाही को प्रदर्शित करता है।
विपक्षी ने अपने लिखित कथन में कहा है कि उसके द्वारा अथक मेहनत और प्रयास तथा सावधानीपूर्वक इलाज किए जाने के बाबजूद परिवादी की पत्नी अत्यधिक गम्भीर स्थिति में होने के कारण वह आपरेशन के कारण कोमा में चली गई। परिवादी के अनुसार उसकी पत्नी की बायीं ह्यूमरस हड्डी में फ्रैक्चर था, अल्ना हड्डी में फ्रैक्चर था, बायें हाथ और दाहिने पैर की एड़ी में फ्रैक्चर था। साथ ही साथ दाहिने पैर में 1/3 डिस्टल फ्रैक्चर था। इसके अतिरिक्त अन्य किसी अन्दरूनी चोट या अन्दरूनी रक्त श्राव का हवाला नहीं दिया गया है।
विपक्षी का कथन है कि उसका अस्पताल ख्याति प्राप्त अस्पताल है जहॉं पर अत्याधुनिक तरीके से आपरेशन होता है और प्रत्येक आपरेशन थिएटर और कमरों में ऑक्सीजन पाइप लगी है जिससे मरीज को ऑक्सीजन दी जाती है।
प्रत्येक आपरेशन करने के पूर्व और आपरेशन के पश्चात् कुछ सावधानियॉं लेनी होती है जो अत्यन्त आवश्यक है, जैसे आपरेशन के पूर्व क्या-क्या कदम उठाने चाहिए इनका सन्दर्भ निम्न लेख से मिल जाएगा :-
Pre-Operative Care For physical preparation, the patient may need to undergo the following:
Medical history and physical exam Share surgical and anesthesia background (such as adverse reaction to anesthesia) Lab tests (CBC, electrolytes, prothrombin time, and urinalysis) EKG for patients with a history of cardiac disease or over 50 years of age Chest X-ray for patients with a history of respiratory disease Risk assessment (nutritional deficiencies, radiation, chemotherapy, steroid use, drug or alcohol abuse, diabetes) Provide current list of medication, vitamins, and herbal supplements Patients may need to take additional steps to prepare for the surgery, depending on the procedure and their unique condition.
Preparation Before surgery, patients should ask their doctor the following questions:
How long will I have to stay in the hospital?
Will I receive any special supplies or medications before going home?
Will I need a caregiver or home aide when I go home?
What are the side effects of surgery?
What are the potential complications?
What should I do or avoid after surgery to support recovery?
When can I return to normal activity?
आपरेशन करने के पश्चात् अस्पताल को क्या-क्या देखना होता है और क्या-क्या सुविधाऐं देनी होती हैं और क्या-क्या आवश्यक कदम उठाने पड़ते है, यह निम्नलिखित लेख से स्पष्ट होता है :-
Immediate postoperative care:
Now an action arises whether there was proper post-operative care taken by the opposite parties after the operation and after the complication developed in the body of the patient.
Postoperative patients must be monitored and assessed closely for any deterioration in condition and the relevant postoperative care plan or pathway must be implemented.
The NCEPOD (2011) report found that patients whose condition was deteriorating were not always identified and referred for a higher level of care. Patients should be made ascomfortable as possible before postoperative checks are performed.
Postoperative patients are at risk of clinical deterioration, and it is vital that this is minimized. Knowledge and understanding of the key areas of risk and local policies will help reduce potential problems (National Patient Safety Agency, 2007; National Institute for Health and Clinical Excellence, 2007).
Track and trigger or early warning systems are widely used in the UK to identify deteriorating patients. These have been adapted by trusts for adults and children and are based on the patient's pulse and respiratory rate, systolic blood pressure, temperature and level of consciousness. Additional monitoring may include pain assessment, capillary refill time, percentage of oxygen administered, oxygen saturation, central venous pressure, infusion rates and hourly urine output.
The National Early Warning Score (NEWS) was developed by a working party to provide a national standard for assessing, monitoring and tracking acutely and critically ill patients (not for use with children under 16 years or in pregnancy); the intention was that trusts would use it to replace their locally adapted early warning systems (Royal College of Physicians, 2012). Like other early warning systems, NEWS has six physiological parameters:
Respiratory rate;
Oxygen saturation;
Temperature;
Systolic blood pressure;
Pulse rate;
Level of consciousness (this will be impaired in patients who have had recent sedation or are receiving opioid analgesia, which should be taken into consideration in assessment).
The system also includes a weighting score of two, which is added if the patient is receiving supplemental oxygen via a mask or nasal cannulas.
When assessing the postoperative patient using NEWS, it is vital that the patient is observed for signs of hemorrhage, shock, sepsis and the effects of analgesia and anesthetic. Patients receiving intravenous opiates are at risk of their vital signs and consciousness levels being compromised if the rate of the infusion is too high. It is therefore imperative that the patient's pain control is managed well, initially by the anesthetist and then the ward staff and pain team or anesthetist, to ensure that the patient has adequate analgesia but is alert enough to be able to communicate and cooperate with clinical staff in the postoperative period.
Many trusts have yet to implement NEWS, although it is beginning to be taught in pre-registration nursing programmes. Student nurses frequently perform postoperative observations under the supervision of a nurse; it is reassuring that they receive some insight and education as recommended by NCEPOD (2011).
Vital signs;
Vital signs should be performed in accordance with local policies or guidelines and compared with the baseline observations taken before surgery, during surgery and in the recovery area.
Nurses should also be aware of the parameters for these observations and what is normal for the patient under observation. When assessing patients' recovery from anaesthesia and surgery, these observations should not be considered in isolation; the nurse should look at and feel the patient. This also applies to children and should include observation of other signs and symptoms, for example abdominal tenderness or poor urine output, which could indicate deterioration (Royal College of Nursing, 2011). The RCN (2011) provides guidance on vital signs performed post-operatively on children. Many trusts now insist that vital signs are performed manually to provide more accurate recording and assessment.
All vital signs and assessments should be recorded clearly in accordance with guidelines for record keeping (Nursing and Midwifery Council, 2009). Handheld personal digital assistants (PDAs) are used at some trusts to store track and trigger data and calculate early warning scores, which can be accessed by the clinical and outreach teams.
When a patient's condition is identified as deteriorating, this information can be passed verbally to appropriate health professionals using the Situation, Background, Assessment and Recommendation (SBAR) tool advocated by the NHS Institute for Innovation and Improvement (2008).
Airway and respirations Respiratory rate and function is often the first vital sign to be affected if there is a change in cardiac or neurological state. It is therefore imperative that this observation is performed accurately; however, studies show it is often omitted or poorly assessed (NPSA, 2007; NCEPOD, 2005).
Nurses should observe and record the following:
Airway;
Respiratory rate (regular and effortless), rhythm and depth (chest movements symmetrical);
Respiratory depression: indicated by hypoventilation or bradypnoea, and whether opiate-induced or due to anaesthetic gases.
Oxygen therapy Oxygen is administered to enable the anaesthetic gases to be transported out of the body, and is prescribed when patients have an epidural, patient-controlled analgesia or morphine infusion. Nurses should ensure and record the following:
Oxygen therapy is prescribed;
Oxygen is administered at correct rate;
Continuous oxygen therapy is humidified to prevent mucous membranes from drying out;
The skin above the ears is protected from elastic on the mask.
Pulse oximetry Oxygen saturation should be above 95% on air, unless the patient has lung disease, and maintained above 95% if oxygen therapy is prescribed to prevent hypoxia or hypoxaemia. An abnormal recording may be due to shivering, peripheral vasoconstriction or dried blood on the finger.
Nurses should ensure that:
The finger probe is clean;
The position of the probe is changed regularly to prevent fingers becoming sore.
Heart rate, blood pressure and capillary refill time The following should be checked and recorded:
Rate, rhythm and volume of pulse;
Blood pressure;
Capillary refill time to assess circulatory status, along with the colour and temperature of limbs, also identifying reduced peripheral perfusion.
Particular attention should be paid to the systolic blood pressure as a lowered systolic reading and tachycardia may indicate haemorrhage and/or shock, although initially the blood pressure may not drop and will remain within normal limits as the body compensates. Tachycardia may also indicate that the patient is in pain, has a fluid overload or is anxious. Hypertension can be due to the anaesthetic or inadequate pain control.
Body temperature Children, older adults and patients who have been in theatre for a long period are at risk of hypothermia. Shivering can be due to anaesthesia or a high temperature indicative of an infection, while a drop in temperature might indicate a bacterial infection or sepsis.
Patients' temperature should be monitored closely and action taken to return it to within normal parameters.
Use a Bair Hugger (forced-air blanket) and blankets to warm the patient if their temperature is too low;
Choose an appropriate method to cool the patient if their temperature is too high (antipyretics/fanning/ tepid sponging).
Level of consciousness .
Postoperative patients should respond to verbal stimulation, be able to answer questions and be aware of their surroundings before being transferred to the ward and throughout the postoperative period.
A change in the level of consciousness can be a sign that the patient is in shock. The AVPU scale (Box 2) is appropriate for assessing consciousness in adults, children and young people unless they have had neurosurgery (RCN, 2011).
Fluid balance The NCEPOD (2011) found, in 30% of patient data reviewed, there was insufficient recording of postoperative fluid balance. Nurses should observe/undertake and record on the fluid balance chart the following:
IV fluids (colloids and crystalloids used to replace fluid loss postoperatively) and infusions;
Oral intake;
Urine output: catheter urine measurements should not be less than 0.5ml/kg/hour. Oliguria can be a sign of hypovolaemia and should be reported to medical staff immediately. Check that the catheter is not kinked or that the patient is not lying on the tubing if urine output is reduced;
Colour of stoma (where appropriate) and whether there is any bleeding;
Nausea and vomiting: if necessary, administration of antiemetics should be checked and vomit bowls and tissues should be within easy reach of the patient;
Oral care;
Nasogastric tube drainage (aspirate if patient feels nauseous unless otherwise indicated);
Colour and amount of wound drainage: large amounts of fresh blood could be an indication of haemorrhage; if there is no wound drainage, it is advisable to check that the drain has not fallen out.
Intravenous infusions The RCN (2010) and Health Protection Scotland (2012) recommend that peripheral venous catheters (PVC) are checked daily as a minimum, and consideration given to removing any PVC that has been in situ longer than 72 hours (Health Protection Scotland, 2012) or 72-96 hours (Department of Health, 2011).
A phlebitis scale can be used to help assess the PVC site; the Visual Infusion Phlebitis Scale (Jackson, 1998) is frequently used and recommended by the RCN (2010). These national guidelines should be used as resources in caring for PVCs. The following should be checked and recorded:
The PVC site when changing IV fluids, before administering IV medication;
Signs of phlebitis (redness, heat and swelling).
Conclusion The postoperative healthcare team is under constant pressure to discharge patients quickly. This can lead to vital signs being missed and result in a delay in recovery.
Patients can be discharged quickly only when they do not experience any post-operative complications, many of which can be avoided or identified with correct and thorough monitoring of signs and symptoms.
All health professionals must continually update their theoretical knowledge and clinical skills; those working in post-operative care can do this by relying less on electronic equipment and developing their ability to combine the use of assessment tools with good observational skills; feeling, listening for abnormal sounds and closely observing their patients.
There are guidelines issued by World Health Organisation for Post Operative Care - these are Postoperative care Post operative note and orders The patient should be discharged to the ward with comprehensive orders for the following:
• Vital signs • Pain control • Rate and type of intravenous fluid • Urine and gastrointestinal fluid output • Other medications • Laboratory investigations The patient's progress should be monitored and should include at least:
• A comment on medical and nursing observations • A specific comment on the wound or operation site • Any complications • Any changes made in treatment Aftercare: Prevention of complications • Encourage early mobilization:
o Deep breathing and coughing o Active daily exercise o Joint range of motion o Muscular strengthening o Make walking aids such as canes, crutches and walkers available and provide instructions for their use • Ensure adequate nutrition • Prevent skin breakdown and pressure sores:
o Turn the patient frequently o Keep urine and faeces off skin • Provide adequate pain control Discharge note On discharging the patient from the ward, record in the notes:
• Diagnosis on admission and discharge • Summary of course in hospital • Instructions about further management, including drugs prescribed.
Ensure that a copy of this information is given to the patient, together with details of any follow-up appointment .
(WHO/EHT/CPR: WHO Surgical Care at the District Hospital 2003 Postoperative Management) If the patient is restless, something is wrong.
Look out for the following in recovery:
• Airway obstruction • Hypoxia • Haemorrhage: internal or external • Hypotension and/or hypertension • Postoperative pain • Shivering, hypothermia • Vomiting, aspiration • Falling on the floor • Residual narcosis The recovering patient is fit for the ward when:
• Awake, opens eyes • Extubated • Blood pressure and pulse are satisfactory • Can lift head on command • Not hypoxic • Breathing quietly and comfortably • Appropriate analgesia has been prescribed and is safely established (WHO/EHT/CPR: WHO Surgical Care at the District Hospital 2003 ) Post operative pain relief • Pain is often the patient's presenting symptom. It can provide useful clinical information and it is your responsibility to use this information to help the patient and alleviate suffering.
• Manage pain wherever you see patients (emergency, operating room and on the ward) and anticipate their needs for pain management after surgery and discharge.
• Do not unnecessarily delay the treatment of pain; for example, do not transport a patient without analgesia simply so that the next practitioner can appreciate how much pain the person is experiencing.
Pain management is our job.
Pain Management and Techniques • Effective analgesia is an essential part of postoperative management.
• Important injectable drugs for pain are the opiate analgesics. Nonsteroidal antiinflammatory drugs (NSAIDs), such as diclofenac (1 mg/kg) and ibuprofen can also be given orally and rectally, as can paracetamol (15 mg/kg).
• There are three situations where an opiate might be given: o Preoperatively o Intraoperatively o Postoperatively • Opiate premedication is rarely indicated, although an injured patient in pain may have been given an opiate before coming to the operating room.
• Opiates given pre- or intraoperatively have important effects in the postoperative period since there may be delayed recovery and respiratory depression, even necessitating mechanical ventilation.
• Short acting opiate fentanyl is used intra-operatively to avoid this prolonged effect.
• Naloxone antagonizes (reverses) all opiates, but its effect quickly wears off.
• Commonly available inexpensive opiates are pethidine and morphine.
• Morphine has about ten times the potency and a longer duration of action than pethidine.
(continued next page) WHO/EHT/CPR: WHO Surgical Care at the District Hospital 2003) Post operative pain relief (continued) • Ideal way to give analgesia postoperatively is to:
o Give a small intravenous bolus of about a quarter or a third of the maximum dose (e.g. 25 mg pethidine or 2.5 mg morphine for an average adult) o Wait for 5-10 minutes to observe the effect: the desired effect is analgesia, but retained consciousness o Estimate the correct total dose (e.g. 75 mg pethidine or 7.5 mg morphine) and give the balance intramuscularly.
o With this method, the patient receives analgesia quickly and the correct dose is given • If opiate analgesia is needed on the ward, it is most usual to give an intramuscular regimen:
¾ Morphine: - Age 1 year to adult: 0.1-0.2 mg/kg - Age 3 months to 1 year: 0.05-0.1 mg/kg ¾ Pethidine: give 7-10 times the above doses if using pethidine • Opiate analgesics should be given cautiously if the age is less than 1 year. They are not recommended for babies aged less than 3 months unless very close monitoring in a neonatal intensive care unit is available.
श्वास की गति तथा अन्य पैरामीटर की भलीभांति जांच आपरेशन के पूर्व की जाती है और यह भी देखा जाता है कि हृदय और नर्वस सिस्टम में किसी प्रकार की कोई अवांछनीय हरकत तो नहीं है। इन सब तथ्यों को एक रजिस्टर में अंकित किया जाता है। आपरेशन के पश्चात रोगी से बोलने की कोशिश की जाती है और मौखिक बातों को समझने के लिए उसके द्वारा व्यक्त प्रतिक्रया को देखा जाता है किन्तु वर्तमान मामले में विपक्षी ने स्वयं स्वीकार किया है कि परिवादी की पत्नी एनेस्थेसिया देते ही कोमा में चली गई किन्तु बहस के दौरान् न्यायालय के समक्ष विपक्षी की ओर से यह नहीं बताया गया कि क्या मरीज की हालत ऐसी थी कि क्या तात्कालिक आपरेशन जरूरी था। एनेस्थेसिया देने से पहले क्या सभी चिकित्सकीय पैरामीटर और मरीज के महत्वपूर्ण अंगी की क्रियाशीलता की जांच भलीभांति कर ली गई थी।
जब कभी भी सर्जरी के लिए कोई मरीज जाता है तब शल्य चिकित्सा से सम्बन्धित एक TEAM बनाई जाती है जो शल्य चिकित्सा की प्रकृति पर निर्भर करता है। इसके लिए कुशल तथा योग्य सर्जन, कुशल और योग्य एनेस्थेटिस्ट, सर्टिफाइड रजिस्टर्ड नर्सें, आपरेटिंग रूम नर्स, सर्जिकल टेक्नीशियन स्टाफ, रेजीडेण्ट डॉक्टर, सहयोगी फिजीशियन और चिकित्कीय उपकरण वाली कम्पनी का प्रतिनिधि होने चाहिए। ये सारे लोग मिल कर आपरेशन की सारी कार्यवाही को देखते हैं और अत्यन्त निरापद वातावरण में मरीज का आपरेशन किया जाता है।
When you have surgery, a team of medical staff helps the surgeon during the operation. Who is on the team depends on the type of surgery. Most teams include the following professionals.
Surgeon A surgeon has finished 4 years of medical school and 4 or more years of special training after medical school. Most surgeons have passed exams for board certification. The American Board of Surgery is the national group that gives this certification for general surgery in the U.S. Some surgeons also have the letters FACS after their name. This means they have approval of the Fellows of the American College of Surgeons (FACS).
Anesthesiologist An anesthesiologist has finished 4 years of medical school and 4 years of special training in anesthesia. Anesthesiologists may get additional training in certain surgery specialties. This might be neurosurgical anesthesia or cardiac anesthesia. The anesthesiologist takes part in all 3 phases of surgery: before, during, and after.
Certified registered nurse anesthetist (CRNA) The nurse anesthetist gives you anesthesia care before, during, and after surgery or labor and delivery. The nurse constantly watches every important function of your body. He or she can change the anesthesia medicine to make sure you are safe and comfortable. A nurse anesthetist has a bachelor's degree in nursing and at least one year of experience as a registered nurse in a critical-care setting. He or she also has at least a master's degree from a nurse anesthetist program. Nurse anesthetists must pass a national certification exam to become CRNAs.
Operating room nurse or circulating nurse Registered nurses are registered and licensed by each state to care for patients. Some nurses focus on a certain field such as surgery. The operating room nurse helps the surgeon during surgery. Operating room nurses are certified in various areas of surgery. Nurses must pass an exam to be certified.
Surgical tech Surgical techs assist with the surgery by setting up a sterile operating room. They get supplies and surgery tools ready. And they hand the surgeon the tools he or she asks for. They must pass an exam to be certified by the National Board of Surgical Assisting (NBSTA).
Residents or medical students In many teaching hospitals, resident doctors in training and medical students may be a part of the surgical team.
Physician assistant Physician assistants practice medicine under the supervision of a doctor. They may act as an assistant to the surgeon. Or they may close incisions with stitches (sutures) or staples.
Medical device company representative Sometimes surgeons will have a representative from a company that makes medical equipment in the operating room. Such equipment might be artificial joints, spine stabilizers, or pacemakers. The representative can help the surgeon with sizing and function of the equipment.
Operating Room Team When a patient is about to undergo a surgical procedure direct patient care will be pass on to the operating room personnel. The operating room (OR) team is responsible for the well-being of a patient throughout the operation. This team should not only consider the patient's privacy but will also promote safety measures for the patient. One way of promoting safety of patients inside the OR is by preventing infection from the surgical incision that will be done.
As described, the OR team is similar to that of a symphony orchestra. There are many members in an orchestra but they work together in unison and harmony to create a superb outcome. The operating room (OR) team does the same thing. They coordinate their work with each other to have a successful operation.
Patients undergoing surgery will be taken care of the operating room team. Safety and privacy of patients in the OR is safeguarded by the operating room team members. Personnel inside the OR consist of the operating surgeon, assistants to the surgeon, a scrub person, an anesthesiologist and a circulating nurse. Each member of the OR team performs specific function in coordination with one another to create an atmosphere that best benefit the patient.
The team is divided into two divisions according to the function of its members.
Sterile OR team: operating surgeon, assistants to the surgeon and scrub person Unsterile OR team: anesthesiologist or nurse anesthetist, circulator and other OR members that might be needed in operating specialized machine or devices.
Classification of OR team There are two types of OR team according to the functions of its members.
Sterile team members Surgeon Assistants to the surgeon Scrub person (either a registered nurse or surgical technologist) Unsterile team members Anesthesiologist Circulator Biomedical technicians, radiology technicians or other staff that might be needed to set up and operate specialized equipment or devices essential in monitoring the patient during a surgical operation Sterile Operating Room Team The members of the OR sterile team will do the following things:
Perform surgical hand washing (arms are included).
Don sterile gowns and gloves.
Enter the sterile field.
Handles sterile items only.
Functions only within a limited area (sterile field).
Wear mask.
Operating Surgeon The surgeon is a licensed physician (MD), osteopath (DO), oral surgeon (DDS or DMD), or podiatrist (DPM). This professional is especially trained and is qualified by knowledge and experience for the performance of a surgical operation.
Responsibilities of a surgeon:
Preoperative diagnosis and care of the patient Performance of the surgical procedure Postoperative management of care Assistants to surgeon During a surgical procedure, the operating surgeon can have one or two assistants to perform specific tasks under his/her (operating surgeon) direction. The responsibilities of a surgeon's assistant:
Help maintain the visibility of the surgical site Control bleeding Close wounds Apply dressings Handles tissues Uses instruments Types of Assistants to Surgeon:
First Assistants could either be:
A qualified surgeon or resident in an accredited surgical education program. The first assistant should be capable of assuming the operating surgeon's responsibility in cases of incapacitation or accidents.
Registered Nurse and surgical technologists that have a written hospital policy permitting the action.
Second Assistant could be a registered nurse or surgical technologist. These staff should be trained and they mar retract tissues and suction body fluids to help provide exposure of the surgical site.
Scrub Person A scrub person could be the following:
Registered Nurse Surgical technologist Licensed practical/vocational nurse The responsibility of a scrub person is to maintain the integrity, safety and efficiency of the sterile field throughout the surgical procedure.
Unsterile Operating Room Team The unsterile operating room members are not allowed to enter the sterile field to prevent contamination. The responsibilities of the members of this team are the following:
Handle supplies and equipments that are considered unsterile.
Touches unsterile surfaces only.
Keep the sterile team supplied with supplies handled aseptically.
Give direct patient care.
Assist the sterile team member's need with strict observation of avoiding contact to the sterile field.
Handles other requirements arising during the surgical procedure.
Anesthesiologist or Anesthetist Difference between an anesthesiologist and anesthetist An anesthesiologist is a medical practitioner who is certified by a certain institution while an anesthetist could either be a qualified and licensed nurse, dentist or a physician who administers anesthetics. The anesthetist works under the supervision of an anesthesiologist or a surgeon when administering a drug or gas.
Responsibilities of an anesthesiologist or anesthetist Choice and application of appropriate agents.
Choice and application of suitable techniques of administration.
Monitoring of physiologic function.
Maintenance of fluid and electrolyte balance.
Blood replacement.
Helps in minimizing the hazards of shock, fire and electrocution.
Use and interpret correctly a wide variety of monitoring devices.
Overseeing the positioning and movement of patients.
Oversee the postanesthesia care unit (PACU) to provide resuscitative care until the patient has regained vital functions.
Circulator A circulator is preferably a registered nurse. However, in some cases a surgical technologist can perform the role of a circulator with the direct supervision from a registered nurse.
Responsibilities of a circulator:
Monitor and coordinate all activities within the room.
Manage the care required for each patient.
Provides assistance to any member of the OR team with strict observation to avoid a break in sterility.
Creates and maintains a safe and comfortable environment for the patient through the implementation of aseptic technique.
किसी भी आपरेशन को करने और एनेस्थेसिया देने के लिए यह आवश्यक है कि उस सम्बन्ध में मरीज की अथवा उसके निकट सम्बन्धी का सहमति पत्र लिया जाए। सहमति पत्र अलग-अलग स्थितियों का अलग-अलग लिया जाता है। वर्तमान मामले में विपक्षी ने एक सहमति पत्र दिनांक 29-03-2016 का दिखाया जिसमें छपे हुए फार्म पर यह लिखा है,'' मेरे मरीज को चोट अपनी गलती से लगी है/बीमारी की बजह से है, इसको आपरेशन के द्वारा ही बेहतर चिकित्सा किया जा सकता है। हम लोगों को आपरेशन एवं बेहोशी के सभी खतरों से अवगत करा दिया गया है। हम सभी कुछ जानने एवं समझने के पश्चात् आपरेशन एवं चिकित्सा कराने के लिए तैयार हैं तथा हम लोग हास्पिटल के सभी नियमों का पालन करने के लिए तैयार हैं। '' इस सहमति पत्र पर डॉक्टर के कोई हस्ताक्षर नहीं हैं जबकि नीचे लिखा है कि हस्ताक्षर एवं पूरा पता : ...... , मेडिकल आफिसर। मरीज की ओर से श्री डी0एन0 सिंह के हस्ताक्षर हैं किन्तु उनका मरीज के साथ क्या सम्बन्ध है, यह स्थापित नहीं है। सहमति पत्र के सम्बन्ध में निम्न लेख को देखना आवश्यक है :-
Consent is a legal requirement of medical practice and not a procedural formality. Getting a mere signature on a form is no consent. If a patient is rushed into signing consent, without giving sufficient information, the consent may be invalid, despite the signature. Often medical professionals either ignore or are ignorant of the requirements of a valid consent and its legal implications. Instances where either consent was not taken or when an invalid consent was obtained have been a subject matter of judicial scrutiny in several medical malpractice cases. This article highlights the essential principles of consent and the Indian law related to it along with some citations, so that medical practitioners are not only able to safeguard themselves against litigations and unnecessary harassment but can act rightfully.
INTRODUCTION Legally, two or more persons are said to consent when they agree upon the same thing in the same sense.[1] Consent must be obtained prior to conducting any medical procedure on a patient. It may be expressed or implied by patient's demeanour. A patient who comes to a doctor for treatment implies that he is agreeable to general physical (not intimate) examination.[2] Express consent (verbal/written) is specifically stated by the patient. Express verbal consent may be obtained for relatively minor examinations or procedures, in the presence of a witness.[3] Express written consent must be obtained for all major diagnostic, anaesthesia and surgical procedures as it is the most undisputable form of consent.
ESSENTIAL PRINCIPLES OF A VALID CONSENT AND THE INDIAN LAW A doctor must take the consent of the patient before commencing a treatment/procedure Except in emergencies, informed consent should be obtained sometime prior to the procedure so that the patient does not feel pressurised or rushed to sign. On the day of surgery, the patient may be under extreme mental stress or under influence of pre-medicant drugs which may hamper his decision-making ability. Consent remains valid for an indefinite period, provided there is no change in patient condition or proposed intervention.[4] It should be confirmed at the time of surgery.[4] Consent must be taken from the patient himself The doctor before performing any procedure must obtain patient's consent.[5] No one can consent on behalf of a competent adult. In Dr. Ramcharan Thiagarajan Facs versus Medical Council of India case,[6] disciplinary action was awarded to the surgeon for not taking a proper informed consent for the entire procedure of kidney and pancreas transplant surgery from the patient. In some situations, beside patient consent, it is desirable to take additional consent of spouse. In sterilisation procedures, according to the Ministry of Health and Family Welfare, Government of India guidelines, consent of spouse is not required.[7] The Medical Council of India (clause 7.16) however states that in case an operation carries the risk of sterility, the consent of both husband and wife is needed.[8] It is advisable to take consent of spouse when the treatment or procedure may adversely affect or limit sex functions, or result in death of an unborn child.[9] In case of minor, consent of person with parental responsibility should be taken.[10] In an emergency, the person in charge of the child at that time can consent in absence of parents or guardians (loco parentis).[11] In a medical emergency, life-saving treatment can be given even in absence of consent.
Refusing treatment in life-threatening situations due to non-availability of consent may hold the doctor guilty, unless there is a documented refusal to treatment by the patient. In Dr. TT Thomas versus Smt. Elisa and Ors case,[12] the doctor was held guilty of negligence for not operating on a patient with life-threatening emergency condition, as there was no documented refusal to treatment.
The patient should have the capacity and competence to consent A person is competent to contract[13] if (i) he has attained the age of majority,[14] (ii) is of sound mind[15] and (iii) is not disqualified from contracting by any law to which he is subject. The legal age for giving a valid consent in India is 18 years.[14] A child >12 years can give a valid consent for physical/medical examination (Indian Penal Code, section 89).[3] Prior to performing any procedure on a child <18 years, it is advisable to take consent of a person with parental responsibility so that its validity is not questioned. If patient is incompetent, then consent can be taken from a surrogate/proxy decision maker who is the next of kin (spouse/adult child/parent/sibling/lawful guardian).[11] Consent should be free and voluntary Consent is said to be free[16] when it is not caused by coercion,[17] undue influence,[18] fraud,[19] misrepresentation,[20] or mistake.[21,22,23] Consent should be informed Consent should be on the basis of adequate information concerning the nature of the treatment procedure.[5] Consent should be informed and based on intelligent understanding. The doctor must disclose information regarding patient condition, prognosis, treatment benefits, adverse effects, available alternatives, risk of refusing treatment and the approximate treatment cost. He should encourage questions and answer all queries.[2] If the possibility of a risk, including the risk of death, due to performance of a procedure or its refusal is remote or only theoretical, it need not be explained.[5] Exceptions to physician's duty to disclose include[24] : (i) Patient refusal to be informed; this should be documented. (ii) If the doctor feels that providing information to a patient who is anxious or disturbed would not be processed rationally by him and is likely to psychologically harm him, the information may be withheld from him (therapeutic privilege); he should then communicate with patient's close relative, family doctor or both.
The "adequate information" must be furnished by the doctor (or a member of his team) who treats the patient.[5] Information imparted should enable the patient to make a balanced judgment as to whether he should submit himself to the particular treatment or not.[5] Consent should be procedure specific Consent given only for a diagnostic procedure, cannot be considered as consent for the therapeutic treatment.[5] Consent given for a specific treatment procedure will not be valid for conducting some other procedure.[5] In Samira Kohli versus Dr. Prabha Manchanda and Anr case,[5] the doctor was held negligent for performing an additional procedure on the patient without taking her prior consent. An additional procedure may be performed without consent only if it is necessary to save the life or preserve the health of the patient and it would be unreasonable to delay, until patient regains consciousness and takes a decision.[5] A common consent for diagnostic and operative procedures may be taken where they are contemplated.[5] Consent obtained during the course of surgery is not acceptable In Dr. Janaki S Kumar and Anr versus Mrs. Sarafunnisa case,[25] in an allegation of performing sterilisation without consent, it was contended that consent was obtained during the course of surgery. The commission held that the patient under anaesthesia could neither understand the risk involved nor could she give a valid consent.
Consent for blood transfusion When blood transfusion is anticipated, a specific written consent should be taken,[24] exception being an emergency situation where blood transfusion is needed to save life and consent cannot be attempted.[26] In M. Chinnaiyan versus Sri. Gokulam Hospital and Anr case,[27] court awarded compensation as patient was transfused blood in the absence of specific consent for blood transfusion.
Consent for examining or observing a patient for educational purpose Prior to examining or observing patients for educational purpose, their consent must be taken.[28] Blanket consent is not valid Consent should be procedure specific. An all-encompassing consent to the effect 'I authorize so and so to carry out any test/procedure/surgery in the course of my treatment' is not valid.[29] Fresh consent should be taken for a repeat procedure A fresh written informed consent must be obtained prior to every surgical procedure that includes re-exploration procedure. In Dr. Shailesh Shah versus Aphraim Jayanand Rathod case,[30] the surgeon was found deficient in service and was liable for compensation as he had performed a re-exploration surgery without a written consent from the patient.
Surgical consent is not sufficient to cover anaesthesia care The surgeons are incapable to discuss the risks associated with anaesthesia. Informed consent for anaesthesia must be taken by the anaesthesia provider as only he can impart anaesthesia related necessary information and explain the risks involved. It may be documented by the anaesthesiologist on the surgical consent form by a handwritten note, or on a separate anaesthesia consent form.[31] Patient has the right to refuse treatment Competent patients have the legal and moral right to refuse treatment, even in life-threatening emergency situations.[31] In such cases informed refusal must be obtained and documented, over the patient's witnessed signature.[32] It may be advisable that two doctors document the reason for non-performance of life-saving surgery or treatment as express refusal by the patient or the authorised representative and inform the hospital administrator about the same.
To detain an adult patient against his will in a hospital is unlawful.[9] If a patient demands discharge from hospital against medical advice, this should be recorded, and his signature obtained.[9] Unilaterally executed consents are void Consent signed only by the patient and not by the doctor is not valid.[33] Witnessed consents are legally more dependable The role of a witness is even more important in instances when the patient is illiterate, and one needs to take his/her thumb impression.[34] Consent should be properly documented Video-recording of the informed consent process may also be done but with a prior consent for the same. This should be documented. It is commonly done for organ transplant procedures. If consent form is not signed by the patient or is amended without his signed authorisation, it can be claimed that the procedure was not consented to.[10] Patient is free to withdraw his consent anytime When consent is withdrawn during the performance of a procedure, the procedure should be stopped. The doctor may address to patient's concerns and may continue the treatment only if the patient agrees. If stopping a procedure at that point puts patient's life in danger, the doctor may continue with the procedure till such a risk no longer exists.[10] Consent for illegal procedures is invalid There can be no valid consent for operations or procedures which are illegal.[24] Consent for an illegal act such as criminal abortion is invalid.[9] Consent is no defence in cases of professional negligence.[9] HOW TO OBTAIN A VALID CONSENT AND CONSENT FORMAT Always maintain good communication with your patient and provide adequate information to enable him make a rational decision.[35] It is preferable to take consent in patient's vernacular language. It may be better to make him write down his consent in the presence of a witness.[34] It is desirable to use short and simple sentences and non-medical terminology that is written/typed legibly.[36] Patient information sheets (PIS) depicting procedure related information, including pre-operative and post-operative pre-cautions in patient's understandable local language with pictorial representation may facilitate the informed consent process. These may help in providing consistently accurate information to the patients.[35] PIS should be handed over to the patients after explaining the contents. Even videos may be used as an aid in increasing patient understanding.[37] Though there is no standard consent format, it may include the following [e.g., Figure 1]:[38] Figure 1 Anaesthesia informed consent form Date and time Patient related: Name, age and signature of the patient/proxy decision maker Doctor related: Name, registration number and signature of the doctor Witness: Name and signature of witness Disease-related: Diagnosis along with co-morbidities if any Surgical procedure related: Type of surgery (elective/emergency), nature of surgery with antecedent risks and benefits, alternative treatment available, adverse consequences of refusing treatment Anaesthesia related: Type of anaesthesia (general and/or regional, local anaesthesia, sedation) including risks Blood transfusion: Requirement and related risks Special risks: Need for post-operative ventilation, intensive care, etc Document the fact that patient and relatives were allowed to ask questions, and their queries were answered to their satisfaction.
CONSENT IN RELATION TO PUBLICATION A registered medical practitioner is not permitted to publish photographs or case reports of his/her patients without their consent, in any medical or another journal in a manner by which their identity could be revealed. However, in case the identity is not disclosed, consent is not needed (clause 7.17).[8] CONSENT IN RELATION TO MEDICAL RESEARCH Consent taken from the patient for the drug trial or research should be as per the Indian Council of Medical Research guidelines[39]; otherwise it shall be construed as misconduct (clause 7.22).[8] COMMON FALLACIES IN THE CONSENT PROCESS The anaesthesiologist must ensure that consent is given maximum importance, and all the legal formalities are followed before agreeing to provide the services. Following are some frequent mistakes and omissions that can cost him/her dearly in the event of a mishap:
Procedure is considered trivial, and consent is not taken Consent of relative is taken instead of the patient, even when patient is a competent adult.
Consenting person is minor, intoxicated or of unsound mind Blanket consent is taken.
It is not procedure specific Consent for blood transfusion is not obtained.
Fresh consent is not taken for a repeat procedure Procedure related necessary information is not given Even if the information given, it is not documented Consent lacks the signature of the treating doctor Consent is not witnessed Alterations or additions are made in the consent form without patient's signed authorisation.
SUMMARY It is not only ethical to impart correct and necessary information to a patient prior to conducting any medical procedure, but it is also important legally. This communication should be documented. Even professional indemnity insurance may not cover for lapses in obtaining a valid consent, considering it to be an intentional assault.
ACKNOWLEDGMENTS We gratefully acknowledge the invaluable contribution and irreplaceable advice extended to us during the preparation of this article by Mr. M Wadhwani, Advocate.
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39. Ethical Guidelines for Biomedical Research on Human Participants. New Delhi: Published by: Director General Indian Council of Medical Research; 2006. [Accessed on 2014 Mar 3]. eral Ethical Issues; pp. 21-33. ] वर्तमान मामले में हमने सहमति पत्र का अवलोकन किया जो प्रवेश के लिए आवेदन पत्र है। इसी के साथ-साथ चिकित्सीय और सर्जीकल उपचार के लिए भी अधिकार पत्र दिया गया है। एक अन्य कालम में ' अपने रोगी को फिजीशियन की राय के विरूद्ध ले जा रहा हूँ ' अंकित है और इस पर भी हस्ताक्षर किए गए हैं। इस तरह से यह एक संयुक्त आवेदन पत्र / अधिकार पत्र और अनापत्ति प्रमाण पत्र हुआ जो गलत है। इस पर मरीज की ओर से किसी डी0एन0 सिंह के हस्ताक्षर हैं जबकि बायीं ओर जहॉं लिखा हुआ है, गवाह के पूर्ण हस्ताक्षर वहॉं सूक्ष्म हस्ताक्षर किए गए हैं जिससे यह पता नहीं चलता कि गवाह कौन है। इस पर किसी भी डॉक्टर के हस्ताक्षर नहीं हैं और न ही डॉक्टर का यह प्रमाण पत्र है कि उसने रोगी या उसके साथ के सहायक को इस आपरेशन के बारे में पूर्ण रूप से समझा दिया है। इस तरह देखा जाए तो यह सहमति पत्र की श्रेणी में नहीं आता है। नीचे स्केण्ड सहमति पत्र को भलीभांति देखा जा सकता है :-
वर्तमान मामले में पूरे घटनाक्रम को देखते हुए यह स्पष्ट होता है कि समस्त परिस्थितियों यह इंगित करती हैं कि इस मामले में विपक्षी सं0-1 की ओर से अत्यन्त लापरवाही और उपेक्षा प्रदर्शित की गई है। परिस्थितियॉं स्वयं बोलती हैं, का सिद्धान्त इस मामले में पूरी तरह से लागू होता है। इस सम्बन्ध में निम्न लेख पर ध्यान दिया जाना आवश्यक है :-
The complexity of the human body and the uncertainty involved in the medical procedure are of such great magnitude that it is impossible for a Doctor to guarantee a successful result; and the only assurance that he can give, or can be understood to have given by implication is that he is possessed of requisite skill in that branch of profession which he is practising and while undertaking the performance of the task entrusted to him, he would be exercising his skills with reasonable competence. An ordinary physician or surgeon is not expected to be either a clodhopper or feckless practitioner of profession, as much as, he is not expected to be a paragon, combining qualities of polymath or prophet as in the realm of diagnosis and treatment, there is ample scope for genuine difference of opinion; and a Doctor cannot be treated as negligent merely because his conclusion differs from that of other persons in the profession, or because he has displayed less skill or knowledge than others would have shown. The true test for establishing negligence in diagnosis or treatment on the part of a doctor is whether he has been proved to be guilty of such failure as no doctor of ordinary skill would be guilty of, if acting with ordinary care.
Furthermore, a golden principle of law has been laid down by the Hon'ble Apex Court in Jacob Mathew Vs. State of Punjab, (AIR 2005 SC 3180) that no sensible professional would intentionally commit an act or omission which would result in loss or injury to the patient as the professional reputation of the person is at stake. A single failure may cost him dear in his career. Even in civil jurisdiction, the rule of res ipsa loquitor is not an 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 by applying the doctrine of res ipsa loquitor.
Yet, another golden principle of law has been laid down by the Hon'ble Apex Court in Indian Medical Association Vs. V.P. Santha's III (1995) CPJ 1 (SC) at para 37 that "it is no doubt true that sometimes complicated questions requiring recording of evidence of experts may arise in a complaint about deficiency in service based on the ground of negligence in rendering medical services by a medical practitioner; but this would not be so in all complaints about deficiency rendering services by a medical practitioner. There may be cases which do not raise such complicated questions and the deficiency in service may be due to obvious faults which can be easily established such as removal of the wrong limb or the performance of an operation on the wrong patient or giving injection of a drug to which the patient is allergic without looking into the out patient card containing the warning or use of wrong gas during the course of an anaesthetic or leaving inside the patient swabs or other items of operating equipment after surgery.
Furthermore, it has been observed in Malay Kumar Ganguli's case (AIR 2010 SC 1162)that" charge of professional negligence on a medical person is a serious one as it affects his professional statusand reputation and as such, the burden of proof would be more onerous. A doctor cannot be held negligent only because something has gone wrong. He also cannot be held liable for mischance or misadventure or for an error in judgment in making a choice when two options are available. The mistake in diagnosis is not necessarily a negligent diagnosis." In the instant matter, thus a simple test, in the light of aforesaid observations, needs to be conducted in order to ascertain whether the Doctor is guilty of any tortious act of negligence/battery amounting to deficiency in conducting a surgery in the delivery of child and not properly attending the patient, the complainant and consequently, liable to pay damages for leaving cotton mass in the abdomen / stomach due to failure in surgery and deteriorating condition of the patient.
Now, it is required to be seen whether an expert report is necessary in each and every case relating to medical negligence or not ? It has been observed by the Hon'ble Apex Court in Indian Medical Association Vs. V.P. Santha III (1995) CPJ 1 (SC) at para 37 that "it is no doubt true that sometimes complicated questions requiring recording of evidence of experts may arise in a complaint about deficiency in service based on the ground of negligence in rendering medical services by a medical practitioner; but this would not be so in all complaints about deficiency rendering services by a medical practitioner. There may be cases which do not raise such complicated questions and the deficiency in service may be due to obvious faults which can be easily established such as removal of the wrong limb or the performance of an operation on the wrong patient or giving injection of a drug to which the patient is allergic without looking into the out patient card containing the warning or use of wrong gas during the course of an anaesthetic or leaving inside the patient swabs or other items of operating equipment after surgery.
Furthermore, in B. Krishna Rao Vs. Nikhil Super Speciality Hospital 2010 (V) SCC513 at para 40 the Hon'ble Apex Court was pleased to hold that it is not necessary to have opinion of the expert in each and every case of medical negligence. The Hon'ble Apex Court was pleased to further hold in Nizam Institute of Medical Sciences Vs. Prashant S. Dhananka and others 2009 (VI) SCC 1 that "in a case of medical negligence, once initial burden has been discharged by the complainant by making of a case of negligence on the part of the hospital or the doctor concerned, the owner then shifts on the hospital or to the attending doctors and it is for the hospital to satisfy the court that there was no lack of care or diligence".
A doctrine or rule of evidence in tort law that permits an inference or presumption that a defendant was negligent in an accident injuring the plaintiff on the basis of circumstantial evidence if the accident was of a kind that does not ordinarily occur in the absence of negligencea plaintiff who establishes the elements of res ipsa loquitur can withstand a motion for summary judgment and reach the jury without direct proof of negligence-- Cox v. May Dept. Store Co., 903 P.2d 1119 (1995).
In Byrne vs Boadle, this maxim was used for the first time where the complainant was injured by a barrel that dropped from the window of the defendant. In the abovementioned case, Pollock, C. B., said "here are many incidents from which no presumption of negligence can arise, but this is not true in every case. It is the duty of persons who keep barrels in a warehouse to take care that they do not roll out and I think that such a case will, beyond all doubt, afford prima facie proof of negligence."
This doctrine intends to help direct the court proceedings to a conclusion, especially if it is established through the implication of this doctrine's rule that the injury caused to the claimant would not have occurred or taken place if the defendant wasn't negligent.This also gives enough cause and evidence to hold the defendant liable for his negligent actions.
The thing speaks for itselfis the gist of the maxim Res Ipsa Loquitur Maxim. What are the essentials of this maxim.
The injury caused to the plaintiff shall be a result of an act of negligence.
There is a lack of evidence, or the evidence presented before the court is insufficient to establish the possibilities of the fault of the plaintiff or third party.
The defendant owes a duty of care towards the plaintiff, which he has breached.
There is a significant degree of injury caused to the plaintiff.
Applicability of Doctrine of Res Ipsa Loquitur.
The maxim of res ipsa loquitur came into force to benefit the plaintiff as he can use circumstantial evidence to establish negligence.
Consequently, it shifts the burden of proof on the defendant, logic being, where there is an event of unexplained cause, usually, the one that does not occur without the defendant's negligence in controlling the action which has caused the injury to the claimant or destroyed his goods.
In this scenario, the court shall presume negligence on the part of the defendant in such a case unless it includes an appropriate explanation compatible with his taking reasonable care.
In AchutraoHaribhauKhodwa and Others vs. State of Maharashtra and Others, it was considered that the maxim should not be applied in the case of general incidences of neglect and shall only be reflected when there is a significant degree of injury caused.
Section 106 of the Indian Evidence Act Section 106 of the Act provides that when any fact is especially within the knowledge of any person, the burden of proving that fact is upon him.
Res ipsa loquitur is a Latin phrase that means "the thing speaks for itself." In personal injury law, the concept of res ipsa loquitur (or just "res ipsa" for short) operates as an evidentiary rule that allows plaintiffs to establish a rebuttable presumption of negligence on the part of the defendant through the use of circumstantial evidence.
This means that while plaintiffs typically have to prove that the defendant acted with a negligent state of mind, through res ipsa loquitur, if the plaintiff puts forth certain circumstantial facts, it becomes the defendant's burden to prove he or she was not negligent.
Res Ipsa Loquitur and Evidence Law Accidents happen all the time, and the mere fact that an accident has occurred doesn't necessarily mean that someone's negligence caused it. In order to prove negligence in a personal injury lawsuit, a plaintiff must present evidence to demonstrate that the defendant's negligence resulted in the plaintiff's injury. Sometimes, direct evidence of the defendant's negligence doesn't exist, but plaintiffs can still use circumstantial evidence in order to establish negligence.
Circumstantial evidence consists of facts that point to negligence as a logical conclusion rather than demonstrating it outright. This allows judges and juries to infer negligence based on the totality of the circumstances and the shared knowledge that arises out of human experience. Res ipsa is one type of circumstantial evidence that allows a reasonable fact finder to determine that the defendant's negligence caused an unusual event that subsequently caused injury to the plaintiff.
This doctrine arose out of a case where the plaintiff suffered injuries from a falling barrel of flour while walking by a warehouse. At the trial, the plaintiff's attorney argued that the facts spoke for themselves and demonstrated the warehouse's negligence since no other explanation could account for the cause of the plaintiff's injuries.
As it has developed since then, res ipsa allows judges and juries to apply common sense to a situation in order to determine whether or not the defendant acted negligently.
Since the laws of personal injury and evidence are determined at the state level, the law regarding res ipsa loquitur varies slightly between states. That said, a general consensus has emerged, and most states follow one basic formulation of res ipsa.
Under this model for res ipsa, there are three requirements that the plaintiff must meet before a jury can infer that the defendant's negligence caused the harm in question:
The event doesn't normally occur unless someone has acted negligently;
The evidence rules out the possibility that the actions of the plaintiff or a third party caused the injury; and The type of negligence in question falls with the scope of the defendant's duty to the plaintiff.
As mentioned above, not all accidents occur because of someone else's negligence. Some accidents, on the other hand, almost never occur unless someone has acted negligently.
Going back to the old case of the falling flour-barrel, it's a piece of shared human knowledge that things don't generally fall out of warehouse windows unless someone hasn't taken care to block the window or hasn't ensured that items on the warehouse floor are properly stored. When something does fall out of a warehouse window, the law will assume that it happened because someone was negligent.The second component of a res ipsa case hinges on whether the defendant carries sole responsibility for the injury. If the plaintiff can't prove by a preponderance of the evidence that the defendant's negligence cause the injury, then they will not be able to recover under res ipsa.
States sometimes examine whether the defendant had exclusive control over the specific instrumentality that caused the accident in order to determine if the defendant's negligence caused the injury. For example, if a surgeon leaves a sponge inside the body of a patient, a jury can infer that the surgeon's negligence caused the injury since he had exclusive control over the sponges during the operation.
In addition to the first two elements, the defendant must also owe a duty of care to protect the plaintiff from the type of injury at issue in the suit. If the defendant does not have such a duty, or if the type of injury doesn't fall within the scope of that duty, then there is no liability.
For example, in many states, landowners don't owe trespassers any duty to protect them against certain types of dangers on their property. Thus, even if a trespasser suffers an injury that was caused by the defendant's action or inaction and that wouldn't normally occur in the absence of negligence, res ipsa loquitur won't establish negligence since the landowner never had any responsibility to prevent injury to the trespasser in the first place.
Res ipsa only allows plaintiffs to establish the inference of the defendant's negligence, not to prove the negligence completely. Defendants can still rebut the presumption of negligence that res ipsa creates by refuting one of the elements listed above.
For example, the defendant could prove by a preponderance of the evidence that the injury could occur even if reasonable care took place to prevent it. An earthquake could shake an item loose and it could fall out of the warehouse window, for instance.
A defendant could also demonstrate that the plaintiff's own negligence contributed to the injury. To go back to the flour-barrel example, if the defendant shows that the plaintiff was standing in an area marked as dangerous it could rebut the presumption of negligence created by res ipsa.
Finally, the defendant could establish that he did not owe the plaintiff a duty of care under the law, or that the injury did not fall within the scope of the duty owed. For example, if the law only imposes a limited duty on the defendant not to behave recklessly, then res ipsa will not help the plaintiff by creating an inference of negligence since a negligent action would not violate the duty owed to the plaintiff.
According to the Blacks Law Dictionary the maxim is defined as the doctrine providing that, in some circumstances, the mere fact of accidents occurrence raises an inference of negligence so as to establish a prima facie (at first sight) case. It is a symbol for that rule that the fact of the occurrence of an injury taken with the surrounding circumstances may permit an inference or recipes omission of negligence, or make out a plaintiff's prima facie case and present a question of fact for defendant to meet with and explanation. It is merely a short way of saying that the circumstances attendant on the accident are of such a nature to justify a jury in light of common sense and past experience in inferring that the accident was probably the result of the defendant's negligence, in the absence of explanation or other evidence which the jury believes.
Its use in clinical negligence gained some traction before Bolam and Bolitho. Mahon v Osborne [1939] 1 All ER 535, is an early example of the application of res ipsa loquitur in a case where a surgical swab had been left inside a patient's body.
In Clarke v Worboys (1952) Times, 18 March, CA, a patient noticed burns on her buttock shortly after surgical excision of a breast tumour. The surgery involved cauterisation. The Court of Appeal held that this was a case where res ipsa loquitur applied. The outcome was not one that would ordinarily occur in the absence of negligence, and the surgical team were unable to explain how the injury was caused.
In Cassidy v Ministry of Health [1951] 2 KB 343, Denning LJ succinctly summarised the maxim's application to clinical negligence cases: "I went into hospital to be cured of two stiff fingers. I have come out with four stiff fingers and my hand is useless. That should not happen if due care had been used. Explain it if you can."
Ng Chun Pui Vs Lee Chuen Tat, the first defendant was driving a coach owned by the second defendant westwards in the outer lane of dual carriageway in Hong Kong. Suddenly the course across the central reservation and collided with a public bus travelling in the inner lane of the other carriageway, killing one passenger in the bus and injuring the driver and three others on the bus. The plaintiff could not prove that the defendants were negligent and had caused the accident. They however proceeded on the basis of Res Ipsa Loquitur and shifted the onus on the defendants to prove that they were not negligent. However, they failed to do so. And the judicial committee of the Privy Council held the defendants liable for the plaintiffs injuries. { MarkLuney and Ken Opliphant, Tort Law Text And Materials (Oxford University Press, New York, 2000) pp 173-175 } In A.S. Mittal &Anr Vs State Of UP &Ors , AIR 1979 SC 1570 , the defendants had organised an eye camp at Khurja along with the Lions Club. 88 low risk cataract operations were undertaken during the period of the camp. It was however, disastrous as many of those who had been operated upon lost their eyesight due to post medical treatment. Proceedings against the government initiated for negligence of the doctors. Damages worth Rs.12,500/- were paid as interim belief to each of the aggrieved. The decision was on the basis of Res Ipsa Loquitur as the injury would not ave occurred had the doctors not been negligent in not having followed up with post-operation treatment. Res Ipsa Loquitur can be applied in matters where are the procedures have not been followed and is not just limited to the commission of an act.
We can define 'Medical negligence' as the improper or unskilled treatment of a patient by a medical practitioner. This includes negligence in taking care from a nurse, physician, surgeon, pharmacist, or any other medical practitioner. Medical negligenceleads to 'Medical malpractices' where the victims suffer some sort of injury from the treatment given by a doctor or any other medical practitioner or health care professional.
Medical negligence can occur in different ways. Generally, it occurs when a medical professional deviates from the standard of care that is required.
So, we can say that any kind of deviation from the accepted standards of medication and care is considered to be medical negligence and if it causes injury to a patient then the doctor who operated on him, other staff and/or hospital may be held liable for this.
Some of the common categories of medical negligence are as follows:
Wrong diagnosis - When someone goes to a hospital, clinic or medical room, etc. the first step after admittance is the diagnosis. Diagnosing symptoms correctly is critical and important to provide medical care to any patient. However, if a patient is not treated properly due to any mistake in diagnosis, the doctor can be made liable for any further injury or damages caused as a result of the wrong diagnosis.
Delay in diagnosis - A delayed diagnosis is treated as medical negligence if another doctor would have reasonably diagnosed the same condition in a timely fashion. A delay in diagnosis can cause undue injury to the patient if the illness or injury is left to worsen with time rather than being treated. Obviously, any delay in the identification and treatment of an injury can reduce the chance of recovery for the patient.
Error in surgery - Surgical operations require an enormous level of skill and it should be done with due care and caution because even the slightest mistakes can have profound effects on the patient. The wrong-site surgery, lacerations of any internal organ, severe blood loss, or a foreign object being left in the body of the patients, all this comes under Surgical error.
Unnecessary surgery - Unnecessary surgery is usually associated with the misdiagnosis of patient symptoms or a medical decision without proper consideration of other options or risks. Alternatively, sometimes surgery is chosen over conventional treatments for their expediency and ease compared to other alternatives.
Errors in the administration of anesthesia - Anesthesia is a risky part of any major medical operation and requires a specialist (anesthesiologist) to administer and monitor its effect on the patient. Prior to any medical procedure requiring anesthesia, the anesthesiologist has to review the patient's condition, history, medications, etc. to determine the most suitable of all the medicine to use. Anesthesia malpractice can happen even during the pre-operation medical review or during the procedure itself.
Childbirth and labor malpractice - Childbirth is a difficult event for a woman and it becomes worse if not handled properly by the doctors and nurses. There are many instances of medical negligence during childbirth including the mishandling of a difficult birth, complications with induced labor, misdiagnosis of a newborn medical condition, etc. Long-Term negligent treatment - Medical negligence can also occur in subtle ways over the course of a long treatment period. Usually, the negligence can take the shape of a failure to follow up with treatment, or a doctor's failure to monitor the effects of the treatment properly.
A standard of care specifies the appropriate treatment and medication procedure as per the requirements that should be taken into account by a doctor while providing the treatment to his patients. The care should not be of the highest degree nor the lowest. Here, the degree means the level of care an ordinary health care professional, with the same training and experience, would render in similar circumstances in the same community. This is the critical question in medical malpractice cases and if the answer is "no," and you suffered injury as a result of the poor treatment, you may file a suit for medical malpractice.
In the case of Dr. Laxman Balkrishna Joshi Vs. Dr. TrimbakBapu Godbole and Anr.[ 1969 AIR 128], the Supreme Court held that a doctor has certain aforesaid duties and a breach of any of those duties can make him liable for medical negligence. A doctor is required to exercise a reasonable degree of care that is set for this profession.
Dr. Kunal Saha vs Dr. Sukumar Mukherjee on 21 October, 2011 ( NC) original petition number 240 OF 1999 is one of the most important case regarding medical negligence. The brief facts of the case are-
Toxic Epidermal Necrolysis ( TEN ) is a rare and deadly disease. It is an extoliative dermatological disorder of unknown cause. A patient with TEN loses epidermis in sheet-like fashion leaving extensive areas or denuded dermis that must be treated like a larze, superficial, partial-thickness burn wound. The incidence of TEN has been reported at 1 to 1.3 per million per year. The female-male ratio is 3:2. TEN accounts for nearly 1% of drug reactions that require hospitalization. TEN has a mortality rate of 25 to 70%.
Smt. Anuradha Saha (in short Anuradha), aged about 36 years wife of Dr. Kunal Saha (complainant) became the unfortunate victim of TEN when she alongwith the complainant was in India for a holiday during April-May 1998. She and the complainant although of Indian original were settled in the United States of America. The complainant is a doctor by profession and was engaged in research on HIV / AIDS for the past fifteen years. Anuradha after acquiring her Graduation and Masters Degree was pursuing a Ph.D. programme in a university of U.S.A. She was a Child Psychologist by profession. Anuradha showed certain symptoms of rashes over her body and received treatment at the hands of Opposite Parties and some other doctors as outdoor patient uptil 10.05.1998 and she was admitted in Advanced Medicare and Research Institute Limited, Calcutta (for short, AMRI), on 11.05.1998, where she was treated by the above-named Opposite Parties and other doctors uptil 16.05.1998. As there was no improvement in her condition, she was shifted to Breach Candy Hospital, Mumbai, on 17.05.1998 by an air ambulance. She was treated in Breach Candy Hospital from 17.05.1998 evening till she breathed her last on 28.05.1998.
Our Complainant as husband of Anuradha felt that the doctors who treated Anuradha and the hospitals where she was treated were grossly negligent in her treatment and her death was occasioned due to gross negligence of the treating doctors and hospitals. Complainant, accordingly, got issued a legal notice to as many as 26 persons i.e. various doctors who treated Anuradha between end of April to the date of her death alleging negligence and deficiency in service on their part and claiming a total compensation exceeding Rs.55 crores from them. Complainant, thereafter filed the present complaint on 09.03.1999 before this Commission claiming a total compensation of Rs. Rs.77,07,45,000/- ( Seventy Seven Crores Seven Lakhs Fourty Five Thousand only). Later he also filed another complaint no. 179 of 2000 in this Commission against Breach Candy Hospital, its doctors and functionaries claiming a further compensation of Rs.25.30 crore ( though the said complaint was later on withdrawn), thereby making claim of compensation exceeding Rs.102 crores, perhaps the highest ever claimed by any complainant for medical negligence before any consumer fora established under the provisions of Consumer Protection Act, 1986 ( in short, the Act). These are some of the facts which make the present case extra ordinary.
The present complaint was filed by the complainant against the above-named opposite parties, namely, Dr. Sukumar Mukherjee, Dr. B. Haldar (Baidyanath Halder), Advanced Medicare and Research Institute Limited ( in short the AMRI Hospital ) and Dr. Balram Prasad and Dr.Abani Roy Chowdhury (physician) and Dr. Kaushik Nandy (plastic surgeon), the Directors of the AMRI Hospital and others claiming a total compensation of Rs. Rs.77,07,45,000/- under different heads alleging various acts of commission and omission on the part of the doctors and hospital amounting to negligence and deficiency in service. Complainant through his brother-in-law Malay Kumar Ganguly also filed criminal complaint against some of the doctors and the hospital under section 304A IPC.
The complaint was resisted by the doctors and the hospital on a variety of grounds thereby denying any medical negligence or deficiency in service on their part. Parties led voluminous documentary and oral evidence and testimonies of some of the witness were even recorded through video conferencing through a Local Commissioner. After a protracted trial and hearing and on consideration of the evidence and material so produced on record and taking note of the legal position governing the question of medical negligence, this Commission ( by a three Member Bench presided over by the then President) dismissed the complaint by an order dated 01.06.2006 holding as under:
In the result, we reiterate that Doctors or Surgeons do not undertake that they will positively cure a patient. There may be occasions beyond the control of the medical practitioner to cure the patients. From the record, it would be difficult to arrive at the conclusion that the injection Depo-Medrol prescribed by Dr. Mukherjee was of such excessive dose that it would amount to deficiency in service by him which was his clinical assessment.
Thereafter, with regard to the alleged deficiency in the treatment given to Mrs. Anuradha by Opposite Party Doctors 2, 3, 5 and 6, there is no substance. The contention against the hospital that it was not having Burns-Ward, and therefore, the deceased suffered is also without substance. Hence, this complaint is dismissed. There shall be no order as to costs.
Aggrieved by the dismissal of his complaint, the complainant filed Civil Appeal (No.1727 of 2007) in the Honble Supreme Court. It would appear that even before the said appeal was filed before the Hon'ble Supreme Court, the Supreme Court was seized of the matter in Criminal Appeal Nos.1191-94 of 2005 filed by Malay Kumar Ganguly, the complainant in the criminal complaint, against the Orders passed by the Calcutta High Court. Since the Criminal Appeals and the Civil Appeal filed by the complainant in the present complaint raised the same questions of fact and law, the Hon'ble Supreme Court heard all the appeals together and decided the same by means of a detailed judgment dated 07.8.2009. By the said order, the Apex Court dismissed the Criminal Appeals filed by Shri Malay Kumar Ganguly but allowed the Civil Appeal No. 1727 of 2007 filed by the complainant and set aside the order dated 01.6.2006 passed by this Commission dismissing the complaint and remanded the matter to this Commission for the limited purpose of determining the adequate compensation, which the complainant is entitled to receive from the subsisting opposite parties by observing as under:
So far as the judgment of the Commission is concerned, it was clearly wrong in opining that there was no negligence on the part of the Hospital or the doctors. We, are, however, of the opinion, keeping in view the fact that Dr.KaushikNandy has done whatever was possible to be done and his line of treatment meets with the treatment protocol of one of the experts viz.. Prof. Jean Claude Roujeau although there may be otherwise difference of opinion, that he cannot be held to be guilty of negligence.
We remit the case back to the Commission only for the purpose of determination of the quantum of compensation. We, keeping in view the stand taken and conduct of AMRI and Dr. Mukherjee, direct that costs of Rs.5,00,000 and Rs.1,00,000 would be payable by AMRI and Dr. Mukherjee respectively.
We further direct that if any foreign experts are to be examined it shall be done only through video conferencing and at the cost of the respondents.
Summary In view of the foregoing discussion, we conclude as under:
The facts of this case viz., residence of the complainant and Anuradha (deceased) in USA and they working for gain in that country; Anuradha having been a victim of a rare and deadly disease Toxic Epidermal Necrolysis (TEN) when she was in India during April-May 1998 and could not be cured of the said disease despite her treatment at two superspeciality medical centres of Kolkata and Mumbai and the huge claim of compensation exceeding Rs.77 crores made by the complainant for the medical negligence in the treatment of Anuradha makes the present case somewhat extraordinary.
The findings given and observations made by the Supreme Court in its judgment dated 07.08.2009 are absolutely binding on this Commission not only as ratio decidendi but also as obiter dicta also, the judgment having been rendered by the Supreme Court in appeal against the earlier order passed by a three Member Bench of this Commission and, therefore, no attempt can be allowed to read down / dilute the findings and observations made by the Supreme Court because the Supreme Court has remitted the complaint to this Commission only for the purpose of determination of the quantum of compensation after recording the finding of medical negligence against the opposite parties and others.
The task entrusted to the Commission may appear to be simple but the facts of the present case and the voluminous evidence led on behalf of the complainant has made it somewhat arduous. Still difficult was the task of apprortionment of the liability to pay the awarded amount by the different opposite parties and perhaps it was for this reason that the Supreme Court has remitted the matter to this Commission.
Multiplier method provided under the Motor Vehicles Act for calculating the compensation is the only proper and scientific method for determination of compensation even in the cases where death of the patient has been occasioned due to medical negligence / deficiency in service in the treatment of the patient, as there is no difference in legal theory between a patient dying through medical negligence and the victim dying in industrial or motor accident. The award of lumpsum compensation in cases of medical negligence has a great element of arbitrariness and subjectivity.
The foreign residence of the complainant or the patient and the income of the deceased patient in a foreign country are relevant factors but the compensation awarded by Indian Fora cannot be at par which are ordinarily granted by foreign courts in such cases. Socio economic conditions prevalent in this country and that of the opposite parties / defendants are relevant and must be taken into consideration so as to modulate the relief. A complainant cannot be allowed to get undue enrichment by making a fortune out of a misfortune. The theoretical opinion / assessment made by a Foreign Expert as to the future income of a person and situation prevalent in that country cannot form a sound basis for determination of future income of such person and the Commission has to work out the income of the deceased having regard to her last income and future prospects in terms of the criteria laid down by the Supreme Court.
There exists no straight jacket formula for apportionment of the awarded compensation amongst various doctors and hospitals when there are so many actors who are responsible for negligence and the apportionment has to be made by evolving a criteria / formula which is just going by the nature and extent of medical negligence and deficiency in service established on the part of different doctors and hospitals.
On a consideration of the entirety of the facts and circumstances, evidence and material brought on record, we hold that overall compensation on account of pecuniary and non pecuniary damages works out to Rs.1,72,87,500/- in the present case, out of which we must deduct 10% amount on account of the contributory negligence / interference of the complainant in the treatment of Anuradha. That will make the net payable amount of compensation to Rs.1,55,58,750/- (rounded ofto Rs.1,55,60,000/-). From this amount, we must further deduct a sum of Rs.25,93,000/- which was payable by Dr. Abani Roy Chowdhury (deceased) or his Legal Representative as the complainant has forgone the claim against them.
In view of the peculiar facts and circumstances of the case and as a special case, we have awarded a sum of Rs.5,00,000/- as cost of litigation in the present proceedings.
The above amount shall be paid by opposite parties no.1 to 4 to the complainant in the following manner:
Dr. Sukumar Mukherjee-opposite party no.1 shall pay a sum of Rs.40,40,000/- (Rupees Forty Lakh Forty Thousand only) i.e. [Rs.38,90,000/- towards compensation and Rs.1,50,000/- as cost of litigation].
Dr. B. Haldar (Baidyanth Halder)-opposite party no.2 shall pay a sum of Rs.26,93,000/- (Rupees Twenty Six Lakh Ninety Three Thousand only) i.e. [Rs.25,93,000/- towards compensation and Rs.1,00,000/- as cost of litigation] AMRI hospital-opposite party no.3 shall pay a sum of Rs.40,40,000/- (Rupees Forty Lakh Forty Thousand only ) i.e. [Rs.38,90,000/- towards compensation and Rs.1,50,000/- as cost of litigation.
(iv) Dr. Balram Prasad-opposite party no.4 shall pay a sum of Rs.26,93,000/- (Rupees Twenty Six Lakh Ninety Three Thousand only) i.e. [Rs.25,93,000/- towards compensation and Rs.1,00,000/- as cost of litigation] The opposite parties are directed to pay the aforesaid amounts to the complainant within a period of eight weeks from the date of this order, failing which the amount shall carry interest @ 12% p.a. w.e.f. the date of default."
इस मामले में एक जांच कमेटी बनाई गई थी जिसमें डॉ0 एल0डी0 मिश्रा पूर्व विभागाध्यक्ष, एनेस्थीसियोलॉजी विभाग, इन्स्टीट्यूट आफ मेडिकल साइंस, बी0एच0यू0 वाराणसी, डॉ0 पंकज कुमार, विभागाध्यक्ष एनेस्थीया विभाग, एन0एस0सी0 सिंगरौली तथा डॉ0 एस0के0 गौतम सीनियर मेडिकल आफीसर (आर्थो), एन0एस0सी0 सिंगरौली थे। इन लोगो ने दिनांक 21-09-2016 को अपेक्स अस्पताल जा कर वहॉं के डॉक्टरों के बयान लिए और अस्पताल तथा सम्बन्धित एनेस्थेसिया प्रकरण का अध्ययन किया।
सभी परिस्थितियों पर विचार करने के उपरान्त यह पाया कि इस अस्पताल में कुछ चीजें नहीं हैं, जिनके लिए लिखा गया। जैसे : EtCO2 मानीटर सभी आपरेशन थिएटर में नहीं पाया गया जहॉं पर जनरल एनेस्थेसिया एण्डोट्रेकियल इन्टूबेशन किया जाता है। जांच समिति ने यह भी लिखा कि डॉ0 सौरभ सुमन एक सीनियर रेजीडेण्ट कम पोस्ट डॉक्टोरल (PDCC) घटना के समय विद्यार्थी थे। सीनियर रेजीडेण्ट एक ट्रेनिंग पोस्ट है जहॉं पर कोई प्राईवेट प्रैक्टिस नहीं होती और उनके द्वारा अपेक्स अस्पताल में एनेस्थेसिया का देना व्यावसायिक दुराचरण की श्रेमी में आता है कि वे एक प्राईवेट अस्पताल में कार्य कर रहे थे। जांच आख्या की स्केण्ड कापी यहॉं अंकित है :-
[RS1] स्पष्ट है कि विपक्षी द्वारा इस मामले में उपेक्षा और लापरवाही दिखाई गई है क्योंकि उन्होंने ऐसे व्यक्ति से एनेस्थेसिया दिलवाया जो सीनियर रेजीडेण्ट के रूप में कार्यरत था और उसे प्राईवेट प्रैक्टिस की अनुमति नहीं थी। इस प्रकार विपक्षी द्वारा व्यावसायिक दुराचरण के साथ-साथ घोर लापरवाही का प्रदर्शन किया गया है।
जब मरीज को दिनांक 01-04-2016 को मेदान्ता हास्पिटल में भर्ती कराया गया तब वहॉं की डिस्चार्ज समरी का अवलोकन किया गया जिसकी स्केण्ड प्रति यहॉं प्रदर्शित की जा रही है :-
इस डिस्चार्ज समरी को देखने से स्पष्ट होता है कि इस मामले में हाई पोक्सिक इस्चीमिया इन्सिफैलोपैथी पाई गई है। यह हाई पोक्सिया एनेस्थेसिया देने के कारण उत्पन्न हुई है जैसा कि निम्न चिकित्सकीय लेख से स्पष्ट होता है :-
hypoxia-due-to-anesthesia One of the basic requirements for us to live is having oxygen to breathe. When deprived of oxygen for just a few minutes, brain cells begin to die. Complete deprivation of oxygen to the brain is called hypoxia, and it can cause serious brain damage or death. This is one of the leading causes of death from anesthesia errors, even more tragic since it is usually preventable. If you or a loved one suffered hypoxia under anesthesia, you may be a victim of medical malpractice.
When under general anesthesia, the body is in a deep state of sedation. It is so deep that you may require oxygenation, or a respirator, to ensure you continue to get the oxygen you need. It is the responsibility of the anesthesiologist and medical team to monitor your breathing and oxygen levels. If oxygen is not getting to your brain while under anesthesia, it could cause permanent damage or death within minutes. Not monitoring a patient closely or the failure of an oxygenating device are anesthesia errors that can cause these serious injuries.
Brain Damage Due to Hypoxia The frustration with anesthesia-caused hypoxia is that it is almost always preventable. A lapse in concentration by an anesthesiologist can result in oxygen deprivation for a few minutes, resulting in damage to the brain. Even if the patient survives, they may face long-term health consequences and a lower quality of life. Some side effects of brain injury caused by hypoxia include:
Memory loss Balance and coordination problems Speech and vision impairments Mental impairments Spasticity इस प्रकार इस मामले में यह स्पष्ट हो जाता है कि विपक्षीगण द्वारा आरम्भ से ही लापरवाही की गई है। एनेस्थेसिया देते समय मरीज की हालत ऐसी नहीं थी कि उसे एनेस्थेसिया दिया जाए किन्तु फिर भी एनेस्थेसिया दिया गया और वह भी एक अकुशल व्यक्ति द्वारा जिसको प्राईवेट प्रैक्टिस करने का कोई अधिकार नहीं था और वह मात्र एक सीनियर रेजीडेण्ट था। उसको इसकी अनुमति अपेक्स अस्पताल के प्रबन्धक ने दी जिसके लिए वह पूर्ण रूप से उत्तरदायी है। परिवादी की पत्नी कोमा में पहुँच गई जिसके लिए पूर्ण रूप से विपक्षी ही उत्तरदायी है। कोमा में होने पर परिवार पर क्या संकट उत्पन्न होता है इसका अनुमान वही लगा सकता है जिसके परिवार में कोई कोमा में हो।
समस्त तथ्यों एवं परिस्थितियों को देखने के उपरान्त हम इस निष्कर्ष पर पहुँचते हैं कि वर्तमान मामले में परिवादी निम्नलिखित अनुतोष पाने का अधिकारी है :-
परिवादी विपक्षी सं0-1 से अपनी पत्नी की हालत के लिए 40.00 लाख रू0 एवं इस पर दिनांक 30-03-2016 से इस परिवाद के निर्णय के दिनांक से 60 दिन के अन्दर 12 प्रतिशत वार्षिक साधारण ब्याज पाने का अधिकारी है और यदि इस निर्णय के 60 दिन के अन्दर भुगतान नहीं किया जाता है तब ब्याज की धनराशि 15 प्रतिशत वार्षिक की दर से दिनांक 30-03-2016 से वास्तविक भुगतान की तिथि तक देय होगी।
परिवादी विपक्षी सं0-1 से चिकित्सीय लापरवाही, मानसिक उत्पीड़न, अवसाद के मद में 30.00 लाख रू0 एवं इस पर दिनांक 30-03-2016 से इस परिवाद के निर्णय के दिनांक से 60 दिन के अन्दर 12 प्रतिशत वार्षिक साधारण ब्याज पाने का अधिकारी है और यदि इस निर्णय के 60 दिन के अन्दर भुगतान नहीं किया जाता है तब ब्याज की धनराशि 15 प्रतिशत वार्षिक की दर से दिनांक 30-03-2016 से वास्तविक भुगतान की तिथि तक देय होगी।
परिवादी विपक्षी सं0-1 से वाद व्यय के रूप में 01.00 लाख रू0 एवं इस पर दिनांक 30-03-2016 से इस परिवाद के निर्णय के दिनांक से 60 दिन के अन्दर 12 प्रतिशत वार्षिक साधारण ब्याज पाने का अधिकारी है और यदि इस निर्णय के 60 दिन के अन्दर भुगतान नहीं किया जाता है तब ब्याज की धनराशि 15 प्रतिशत वार्षिक की दर से दिनांक 30-03-2016 से वास्तविक भुगतान की तिथि तक देय होगी।
विपक्षी सं0-1, विपक्षी सं0-2 से बीमित धनराशि के सापेक्ष प्रतिपूर्ति पाने का अधिकारी होगा।
वर्तमान परिवाद तदनुसार आंशिक रूप से स्वीकार किए जाने योग्य है।
आदेश वर्तमान परिवाद आंशिक रूप से स्वीकार किया जाता है। विपक्षी सं0-1 को आदेश दिया जाता है कि वह परिवादी को उसकी पत्नी की हालत के लिए 40.00 लाख रू0 एवं इस पर दिनांक 30-03-2016 से इस परिवाद के निर्णय के दिनांक से 60 दिन के अन्दर 12 प्रतिशत वार्षिक साधारण ब्याज का भुगतान करे और यदि इस निर्णय के 60 दिन के अन्दर भुगतान नहीं किया जाता है तब ब्याज की धनराशि 15 प्रतिशत वार्षिक की दर से दिनांक 30-03-2016 से वास्तविक भुगतान की तिथि तक देय होगी।
2. विपक्षी सं0-1 को आदेश दिया जाता है कि वह परिवादी को चिकित्सीय लापरवाही, मानसिक उत्पीड़न, अवसाद के मद में 30.00 लाख रू0 एवं इस पर दिनांक 30-03-2016 से इस परिवाद के निर्णय के दिनांक से 60 दिन के अन्दर 12 प्रतिशत वार्षिक साधारण ब्याज का भुगतान करे और यदि इस निर्णय के 60 दिन के अन्दर भुगतान नहीं किया जाता है तब ब्याज की धनराशि 15 प्रतिशत वार्षिक की दर से दिनांक 30-03-2016 से वास्तविक भुगतान की तिथि तक देय होगी।
3. विपक्षी सं0-1 को आदेश दिया जाता है कि वह परिवादी को वाद व्यय के रूप में 01.00 लाख रू0 एवं इस पर दिनांक 30-03-2016 से इस परिवाद के निर्णय के दिनांक से 60 दिन के अन्दर 12 प्रतिशत वार्षिक साधारण ब्याज का भुगतान करे और यदि इस निर्णय के 60 दिन के अन्दर भुगतान नहीं किया जाता है तब ब्याज की धनराशि 15 प्रतिशत वार्षिक की दर से दिनांक 30-03-2016 से वास्तविक भुगतान की तिथि तक देय होगी।
4. विपक्षी सं0-1, विपक्षी सं0-2 से बीमित धनराशि के सापेक्ष प्रतिपूर्ति पाने का अधिकारी होगा।
यदि विपक्षी सं0-1 अपेक्स अस्पताल इस निर्णय के 60 दिन के अन्दर इस आदेश का पालन नहीं करता है तब परिवादी को अधिकार होगा कि वह विपक्षी सं0-1 के व्यय पर इस न्यायालय के समक्ष उसके विरूद्ध निष्पादन वाद प्रस्तुत करे।
उभय पक्ष को इस निर्णय की प्रमाणित प्रति नियमानुसार उपलब्ध करायी जाय।
वैयक्तिक सहायक से अपेक्षा की जाती है कि वह इस निर्णय को आयोग की वेबसाइट पर नियमानुसार यथाशीघ्र अपलोड कर दें।
(सुशील कुमार) (राजेन्द्र सिंह) सदस्य सदस्य
निर्णय आज खुले न्यायालय में हस्ताक्षरित, दिनांकित होकर उद्घोषित किया गया।
(सुशील कुमार) (राजेन्द्र सिंह) सदस्य सदस्य दिनांक :- 26-04-2023. प्रमोद कुमार, वैय0सहा0ग्रेड-1, कोर्ट नं.-2. [HON'BLE MR. Rajendra Singh] PRESIDING MEMBER [HON'BLE MR. SUSHIL KUMAR] JUDICIAL MEMBER