National Consumer Disputes Redressal
Dr. Jose Joseph & Anr. vs C.S. Raju & Ors. on 11 January, 2018
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI APPEAL NO. 91 OF 2008 (Against the Order dated 29/09/2007 in Complaint No. 03/2000 of the State Commission Kerala) 1. DR. JOSE JOSEPH & ANR. J.J. HOSPITAL, KRISHNAPURAM, KAYAMKULAM, ALAPPUZHA DISTRICT, KERALA ...........Appellant(s) Versus 1. C.S. RAJU & ORS. CHIRAPPARATHU THEKKETHIL HOUSE, KAPPIL EAST, KRISHNAPURAM, KAYAMKULAM,ALAPPUZHA D KERALA 2. RESHMA RAJU, CHIRAPPARATHU THEKKETHIL HOUSE, KAPPIL EAST, KRISHNAPURAM, KAYAMKULAM,ALAPPUZHA DI KERALA 3. RAJESH CHIRAPPARATHU THEKKETHIL HOUSE, KAPPIL EAST, KRISHNAPURAM, KAYAMKULAM,ALAPPUZHA DI KERALA ...........Respondent(s)
BEFORE: HON'BLE MR. DR. B.C. GUPTA,PRESIDING MEMBER HON'BLE MR. DR. S.M. KANTIKAR,MEMBER For the Appellant : Ms. Ramandeep Kaur, Advocate For the Respondent : Mr. Shyam Padman, Advocate with Mr. Jaimon Andrews, Advocate Dated : 11 Jan 2018 ORDER DR. S. M. KANTIKAR, MEMBER Emergency obstetric hysterectomy is a radical, most challenging, life saving operation that is mostly done for indications that are life-threatening for the patient. Quick decision making and performing the operation speedily are the two most important surgeon-related factors that affect the maternal and foetal outcome.
1. This first appeal has been filed under Section 19 of the Consumer Protection Act, 1986 against the order dated 29.09.2007 passed in complaint case No. 3 of 2000 by Kerala State Consumer Disputes Redressal Commission, Thiruvananthapuram (in short, 'the State Commission') whereby the complaint of the complainant was allowed.
2. The brief facts of the case are that on 23.1.1998, Smt. K. Raji, wife of the complainant, since deceased (hereinafter referred as 'the patient') for second delivery, was admitted in J. J. Hospital/OP 2. On 26.1.1998, Dr. Jose Joseph/OP-1 informed Mr. C. S. Raju, husband of the patient about the need of cesarean operation (LSCS). On the same day, a male baby was delivered by LSCS but, the patient suffered severe blood loss (during delivery). The OP-1 informed to get AB+ve blood immediately. It was arranged by the complainant, but OP-1, again asked to bring A+ve blood instead of AB+ve. Accordingly, complainant arranged sufficient A+ve blood as well as few blood donors. The relatives were kept in dark about the happenings inside the operation theatre and later on, OP/hospital informed that the patient was no more. Due to alleged medical negligence causing death of the patient, the complainants i.e. patient's husband, C. S. Raju and two minor children, Reshma Raju and Rajesh filed a complaint on 25.1.2000 before Kerala State Consumer Disputes Redressal Commission, Thiruvananthapuram (in short, 'the State Commission') for compensation of Rs. 30 lakhs.
3. The OPs filed written version and denied any negligence on their part. It was submitted that the patient approached OP-1 with the history of two months amenorrhoea, the Urine Pregnancy Test was positive. She informed, her blood group as AB+. The patient attended regular Antenatal check-up for five times, the USG and routine tests were normal. The patient was admitted in the OP-2/hospital for delivery on 23.1.2000. As there was no progress in labour, hence, the cesarean operation was imminent. After informed consent, the LSCS was performed by OP-2 under spinal anesthesia. A male baby was delivered and tubectomy was also performed as requested by the patient. It was further stated that, the uterus was not contracting despite administration of medicines, there was profuse bleeding. Hence, OP 2 performed sub-total hysterectomy. Blood was sent for cross matching, but it was found that blood was not clotting due to coagulation failure. Five units of blood was administered, but bleeding did not stop. The abdomen was closed after putting two Radivac Suction, one through the cervix and anterior abdominal wall to check for further internal bleeding. Oxygen saturation was 100%. The BT & CT also improved. The patient later on developed cardiac arrest and she was resuscitated with D. C. shock and other supportive measures. But despite all measures, she suffered second cardiac arrest and expired. Hence, there was no negligence on the part of OP 1.
4. The State Commission examined the witnesses and on the basis of evidence, allowed the complaint and directed the OP-1 to pay Rs. 5 lakh alongwith costs of Rs.1500/-. Being aggrieved by the order, the OPs-1 and 2(Appellants) have filed appeal before this Commission.
5. We have heard the exhaustive arguments from learned counsel for both the parties. Counsel for the complainant submitted that the hospital was deficient in their services because, basic investigation like blood group was not performed before delivery or never advised any blood tests. Only at emergency hours, OP-1 informed the relatives of patient about the need for 'AB+ve' blood. The hospital failed to keep blood ready before the surgery. The death of patient was due to bleeding. The OP-2 did not perform hysterectomy for stoppage of bleeding. It is proved from the PM report also that the uterus was intact when the PM was performed.
6. Learned counsel for the OPs submitted that as a routine practice during his first Antenatal visit, the patient was advised to undergo basic investigation and also she was informed about the need of blood in case of cesarean delivery. Accordingly, it was informed to the relatives of patient to arrange few live blood donors of the same blood group of the patient. The counsel further submitted that the patient confidently revealed her blood group as 'AB+ve'. The OP believed it because the patient was educated and a high school teacher. The patient developed PPH after delivery and therefore, blood was sent for cross matching, but the patient's blood was found to be 'A+ve' instead of 'AB+ve', therefore, again 'A+ve' blood requested. The doctors at OP transfused 'A+ve' blood. Due to severe PPH, there was derangement of blood coagulation. Therefore, the OP performed sub-total hysterectomy to stop bleeding. The counsel further submitted that, the PM findings recorded as 'presence of uterus' was a wrong finding, because the gravid uterus after sub-total hysterectomy appears as to the size of normal uterus.
7. We have perused the medical on record, PM report and the supportive medical literature and gave our thoughtful consideration to the arguments advanced by both the parties. It is an admitted fact that the patient had undergone cesarean operation at OP-2/hospital. It was performed by OP-1. The baby was delivered without any complication. Thereafter, the patient suffered profuse bleeding i.e. PPH. As per the medical record and during ANC, patient had mentioned her blood group as AB+ve. Accordingly, OP-1 advised the husband of patient to arrange AB+ve blood but, during cross matching, it was found that the patient's blood group was A+ve instead of AB+, hence, OP-1 advised to bring A+ve blood, which has caused delay to arrange the blood. In our view, the treating doctor failed to advise basic investigations including blood group during ANC follow up or before surgery. Just relying upon patient's word that her blood group was AB+ve is not an accepted practice or a diligent attitude of the OP-2. It is quite common that a layman often do not remember his blood group or wrongly interpret it. Therefore, it was the duty of the hospital or doctor to ascertain the group of patient on the basis of any laboratory report or subjecting the patient for blood group test again before delivery. In the instant case, the OP-1 had failed to check the blood group prior to or at the time of delivery. Therefore, OP is liable to that extent only. Secondly, due to PPH, to save the life of the patient, OP-1 had performed sub-total hysterectomy. It was a correct decision and accepted standard line of treatment during obstetrics emergency. Thirdly, the PM report which was totally wrongly interpreted. The PM was conducted by Dr. S. Sivasuthan, PW2 on 28.1.1998, which opined that the death was due to transfusion reaction, but finding also stated that the sub-total hysterectomy was not done. If we read the PM report carefully, as per PM report, the curved sutured wound 15 cms long over the front of the lower abdomen just above the pubic symphysis. The abdominal wall beneath was found closed in layers, uterus 12X9X4 cms with sutured wound across its lower segment 14 cms long. Its cavity was empty. Cervix was oedematous and lax (14 cms in circumference) Adnexae were normal. Abdominal cavity contained 210 ml of blood stained fluid. The rest of PM findings were insignificant.
8. The main controversy is whether the OP performed sub-total hysterectomy upon the patient to arrest the bleeding or not ? The post mortem report clearly revealed that the uterus was flabby 12X9X4 cm of sutured wound across its lower segment 14 cm long. The patient developed Atonic PPH, i.e. uterus fails to contact after delivery. If we presume sub-total hysterectomy was not performed by OP; then the size of uterus would be about 30 to 36 cm. X 10 to 15 cm X 20 to 25 cm and lower segment will be only 10 to 12 cms. Thus, the PM findings regarding flabby uterus, measuring 12 X 9 X 4 cms. with sutured wound of 14 cms. across lower segment, it clearly establishes that it was uterus after sub-total hysterectomy. It is pertinent to note that the PW-2/doctor himself admitted that he had performed the post mortem without following mandatory guidelines, as mentioned in the Current Method of Autopsy practice' by Lud Wig. He did not verify the hospital records before performing PM, did not consult or sought assistance of Gynaecologist as the mandatory requirements. Thus, in our view, PM report was inconclusive issued without following standard guidelines.
9. In our view, the State Commission has wrongly appreciated the PM report in which the doctor, who performed PM mentioned that uterus was intact measuring 12 X 9 X 4 cms. He was PW-2 and stated in his evidence that hysterectomy was not done. We are rather surprised by this finding. As stated supra (para 9), the finding was wrong. To understand sub-total hysterectomy during obstetrics emergency, we took reference from few books on operative Obstetrics and Gynecology like operative Gynecology by Te Linde's (10th Edition), Munro-Kerr's (12th Edition), Operative Obstetrics, the Shaw's book of Gynecology and Williams Obstetrics. The sub-total hysterectomy means the body of uterus will be resected out and the remaining lower part of uterus alongwith cervical stump will be left by putting stitches on the surgical margin. Therefore, remaining part of uterus alongwith oedematous cervical and mimics as normal uterus. The diagram etc. representation is as below:
10. Peripartum hysterectomy is the surgical removal of pregnant uterus alone or with the cervix during cesarean section (cesarean hysterectomy) or shortly following vaginal delivery (postpartum hysterectomy). It is one of the most challenging and life saving obstetric maneuver reserved for situations where obstetric hemorrhage fails to respond to conservative treatment. It is more preferred, because it is technically easier, with shorter operating time, less blood loss and urological injury and lower morbidity. The good obstetric judgment should be applied in deciding cases for emergency hysterectomy as a last resort to saving the life of mother and the baby.
11. In our view, the State Commission has erroneously appreciated the Post Mortem report that uterus was not removed. It was the mistake of the doctor, who performed post mortem. He has wrongly mentioned in the Post Mortem report that uterus was present but in fact, it was the remaining part of gravid uterus after sub-total hysterectomy. On the basis of foregoing discussion, we do not find any negligence committed by OP/doctor while performing delivery and the sub-total hysterectomy. It was performed to stop the bleeding from uterus and it was needed to save the life of the patient. So far as the issue of blood group is concerned, as discussed in para 7, the OP/Hospital is liable for the mental agony suffered by the relatives of the patient. Therefore, we modify the order of State Commission and direct the OPs to pay the compensation to the extent of Rs. 1 lakh alongwith interest @9% per annum from the date of filing of the complaint. The OPs shall comply the order within six weeks from the date of receipt of a copy of this order, failing which, OPs shall be liable to pay interest @ 12% per annum till its realization. With this modification, the appeal is disposed of.
...................... DR. B.C. GUPTA PRESIDING MEMBER ...................... DR. S.M. KANTIKAR MEMBER