National Consumer Disputes Redressal
Sujit Kumar Nandi Through Lrs. & Anr. vs Ramakrishna Mission Seva Pratisthan & 7 ... on 29 March, 2023
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI FIRST APPEAL NO. 464 OF 2014 (Against the Order dated 10/06/2014 in Complaint No. 04/2009 of the State Commission West Bengal) 1. SUJIT KUMAR NANDI through LRs. & ANR. S/O. LATE DR. KANAILAL NANDI, R/O. AT 28, PRATAPADITYA PLACE, POLICE STATION- TOLLYGUNGE KOLKATA - 700 026 2. SMT. NUPUR NANDI WIFE OF SRI SUJIT KUMAR NANDI, R/O. AT 28, PRATAPADITYA PLACE, POLICE STATION-TOLLYGUNGE, KOLKATA-700026 ...........Appellant(s) Versus 1. RAMAKRISHNA MISSION SEVA PRATISTHAN & 7 ORS. REPRESENTED BY ITS SECRETARY SWAMI SARVALOKANDA, ALIAS "SISHUMANGAL HOSPITAL HAVING ITS OFFICE AND ESTABLISHMENT AT 99, SARAT BOSE ROAD, POLICE STATION-TOLLYGUNGE, KOLKATA - 700 026 2. DR. DHIMAN GANGULY SENIOR DOCTOR, S/O. OF LATE SAKTIPADA GANGULY, R/O. AT 90A/1B, SUREN SARKAR ROAD, POLICE STATION-BELIAGHATA, KOLKATA-700010 3. DR. N.S. NARAYAN, SENIOR DOCTOR S/O. LATE K.R. NARAYANSWAMY, R/O. AT 28/4, GARIAHAT ROAD, (S) POLICE STATION-LAKE, KOLKATA-700029 4. DR. ASHIS PATRA, A RESIDENT ANESTHETIST OF THE SAID RAMAKRISHNA MISSION SEVA PRATISTHAN OF 99, SARAT BOSE ROAD, POLICE STATION-TOLLYGUNGE KOLKATA - 700 026 5. DR. HINDOL DASGUPTA A SENIOR DOCTOR, S/O. ASHIM RANJAN DASGUPTA, R/O. AT 42C, SAYED AMIR ALI AVENUE, POLICE STATION -KARAYA, KOLKATA-700072 6. DR. JAYANTA SINHA A RESIDENT MEDICAL OFFICER, S/O. JOGABARA SINHA R/O. AT NILACHAL APARTMENT NABAPALLY, JOKA POLICE STATION-JOKA KOLKATA-700104 WEST BENGAL. 7. DR. ANANYA BISWAS, A RESIDENT MEDICAL REGISTRAR, RESIDING AT 1/5, IBRAHIMPUR ROAD, GOVT. HOUSING ESTATE, JADAVPORE, POLICE STATION-JADAVPUR, KOLKATA - 700 032 8. DR. PRASUN GHOSH A RESIDENT MEDICAL OFFICER, RESIDING AT /81/2A, BELGACHIA ROAD, POLICE STATION-BELGACHIA, KOLKATA - 700 037 ...........Respondent(s)
BEFORE: HON'BLE DR. S.M. KANTIKAR,PRESIDING MEMBER
For the Appellant : For the Respondent :
Dated : 29 Mar 2023 ORDER
Appeared at the time of arguments
For the Appellants : Ms. Sumita Roy Chowdhury, Advocate
For the Respondents : Mr. Sukalyan Sarkar, Advocate for R-1, 4, 6, 7 & 8
Mr. Rishad Medora, Advocate & Ms. Surbhi Dhanuka, Advocate for R-2, 3 & 5
with Dr. N.S. Narayan, R-3 in person
Organophosphorus (OP) compounds are largely used as pesticides worldwide. Their easy availability and lack of knowledge about their seriousness resulting increase in accidental and suicidal poisoning. According to a World Health Organization (WHO) report, every year three million cases of poisonings with insecticides occur worldwide resulting in approximately 200,000 deaths
1. This First Appeal has been filed under Section 19 of the Consumer Protection Act, 1986 (in short, the 'Act') against the Order dated 10.06.2014 passed by the State Consumer Disputes Redressal Commission, West Bengal (for short 'State Commission) in Complaint Case No.SC-9/O/2004, whereby the Complaint was dismissed.
2. The case of Complainants that on 18.05.2002, their daughter- Nabanita Nandi,15 years age (for short 'patient') accidently consumed Baygon insecticide granules and admitted to Ramkrishna Mission Seva Pratisthan Hospital (OP-1) (for short 'the hospital') in Kolkata. After first aid, it was alleged that the patient was given excessive doses of Atropine, which resulted into her premature death. It was further alleged that the doctors did not inform about the condition of patient and not suggested for transfer to any other hospital. They did not take opinion of medical expert before administering heavy doses of Atropine. Being aggrieved, the Complainants filed the Consumer Complaint and prayed compensation of Rs.75 lakh and other reliefs.
3. The OPs, in their reply, denied allegations of medical negligence. It was registered as MLC case of unknown poisoning. It was submitted that the patient was admitted in C-3 ward in restless condition. She vomited after ingestion of sleeping tablets (Diazepam) and Baygon granules. The blood samples were taken for investigation. The patient was treated with inj. Atropine as per standard treatment and she was monitored continuously. On 19.05.2002, the visiting physician OP-2 examined her with the junior doctors and found that the patient was feverish with dilated non-reactive pupils. Therefore, as per his instruction Atropine injection was stopped after 7:45 am. The patient was transferred to the I.T.U. on next day in comatose state and put on ventilatory support. However, despite all efforts, she expired at 3 a.m. due to lethal dose of Baygon and Diazepam. The specific treatment and dosages of Atropine depend on severity and duration of poison exposure.
4. The State Commission dismissed the Complaint. Being aggrieved the Complainant filed the instant appeal.
5. Heard the arguments from the learned counsel for the parties. The learned counsel for Complainant argued that the State Commission overlooked the findings of medical experts. As per Modi's Medical Jurisprudence, before treating OP poisoning, a blood sample should be collected to estimate Cholinesterase activity to confirm the diagnosis of poisoning. Also, before Atropine administration, adequate oxygenation was necessary, but the treating doctors failed to take necessary steps. Unfortunately the attending junior / trainee and resident doctors were not competent to treat the patient.
6. The learned Counsel for the OP argued that on admission, it was diagnosed as OP poisoning. She had supra-ventricular tachycardia. Her stomach wash was done and she was admitted and kept under observation. The doctors at OP-1 are honorary consultants and they were not employees or agents of the hospital.
7. The crucial issue involved in the instant case that whether the death of patient was due to excessive doses of Atropine.
8. I have carefully perused the medical record. On 18.05.2002, the patient's blood investigations were within normal limits. The senior doctors - Dr. Dhiman Ganguly (OP-2) and Dr. N. S. Narayan (OP-3) treated the patient with Atropine. They advised to administer about 102 ampoules of Atropine injections till 10 a.m. on 19.05.2002. The Forensic expert Prof. (Dr.) Ajoy Kumar Gupta (Rtd.) opined that it was severe Atropine poisoning because of reckless administration of 142 ampoules to the minor patient within a short span of 20 hours. The PM report was incomplete with respect to chemical analysis of the viscera.
9. I further note that although multiple antidotes had been proposed for the treatment of OP poisoning; only a single antidote - the muscarinic receptor antagonist Atropine - has efficacy in the treatment. According to Modi's textbook of Forensic Medicine, much larger doses of Atropine are often needed for OP poisoning than used for other indications. In the instant case, the doctors in order to achieve adequate and fast atropinisation, the doubling dose approach was used, like escalation of doses from 1 mg to 2 mg, 4 mg, 8 mg, 16 mg, and so on. Thus, much larger doses of Atropine are often needed for OP poisoning.
10. The endpoint for atropine use is dried salivary, pulmonary secretions and adequate oxygenation. Tachycardia and mydriasis must not be used to limit or to stop subsequent doses of Atropine. The main concern with OP toxicity is respiratory failure from excessive airway secretions. Start with a 1-2 mg IV bolus, repeat 3-5 min till desired effects[1] (drying of pulmonary secretions and adequate oxygenation). An Atropine drip titrated to the above endpoints can be initiated until the patient's condition is stabilized.
11. I have gone through various literatures on Atropine from the Modi's Medical Jurisprudence & Toxicology (22 ed.), Davidson's Prinicple & Practice of Medicine (19th ed.), Harrison's Internal Medicine etc. Organophosphates are one of the most common causes of poisoning especially in developing countries with mortality rates reaching up to 10- 20%. So early diagnosis and appropriate treatment is often lifesaving[2]. The antidotes of OP poisoning are anticholinergic drugs such as atropine and glycopyrrolate, atropine being the older of the two medications. Muscarinic effects of OP poisoning are reversed by these drugs. Conventional treatment with atropine may lead to CNS toxicity, although control of secretions may still be inadequate. Glycopyrrolate (glycopyrronium bromide) is a quaternary ammonium with anti-muscarinic activity and peripheral actions like to that of atropine, however glycopyrrolate is twice as potent as atropine for peripheral effects. It can be safely use during pregnancy as it doesn't cross the placental barrier. Glycopyrrolate can't pass through the Blood Brain Barrier (BBB), so it does not have any detectable central anti-cholinergic effects. Atropine is universally accepted antidote, most frequently used for the patients of OP poisoning. Some of the previous studies revealed that atropine treatment is effective, however it often causes agitation, hallucinations and confusion.
12. It is known that Atropine is administered intravenously to restore adequate cardiorespiratory function rapidly - a process often termed 'atropinzation'. It is used to reverse bradycardia and improve systolic blood pressure to greater than 80 mmHg. The Atropine infusion in OP poisoning is to be continued till recovery. Airway control and adequate oxygenation are paramount in organophosphate (OP) poisonings. Intubation may be necessary in cases of respiratory distress due to laryngospasm, bronchospasm, bronchorrhea, or seizures. Immediate aggressive use of atropine may eliminate the need for intubation. Succinylcholine should be avoided because it is degraded by plasma cholinesterase and may result in prolonged paralysis.
13. If atropine is unavailable or in limited supply, intravenous glycopyrrolate or diphenhydramine may provide an alternative anticholinergic agent for treating muscarinic toxicity; however, glycopyrrolate does not cross the blood-brain barrier and cannot treat central effects of OP poisoning.
14. It is pertinent to note that, history of the patient clearly states that there was a familial disharmony due to which Nandita (patient) consumed a handful of Baygon Granules and Diazepam tablets at her home at about 6-00 p.m. and she was brought to the emergency of OP-1 hospital at 7.55 p.m. Emergency first aid and treatment was started. There was no harm in feeding orally with the Ryle's tube in position, but it is unlikely that one would have fed this patient because of the worry about vomiting which was very common in such poisoning and risks of aspirating the vomitus into the respiratory tract. After the stomach wash, clear instruction was given to keep patient Nil by mouth till further advise and 4 hourly suction through Ryle's tube. The administration of Atropine in large quantity was an accepted standard of care. It was not excessive doses of Atropine. The treating doctors provided ICU care with proper investigations. Thus relying upon the standard text books, the negligence is not visible from the hospital or the treating doctors.
15. The concept of medical negligence has been elaborated in several judgments of Hon'ble Supreme Court. In Achutrao Harbhau Khodwa Vs. State of Maharashtra[3] case it was held that:
" The skill of medical practitioner differs from doctor to doctor. The nature of the profession is such that there may be more than one course of treatment which may be advisable for treating a patient. Courts would indeed be slow in attributing negligence on the part of a doctor if he has performed his duties to the best of his ability and with due care and caution. Medical opinion may differ with regard to the course of action to be taken by a doctor treating a patient, but as long as a doctor acts in a manner which is acceptable to the medical profession and a court finds that he has attended on the patient with due care skill and diligence and if the patient still does not survive or suffers a permanent ailment, it would be difficult to hold the doctor to be guilty of negligence."
16. The appellants (complainants) failed to prove their case, not placed any cogent evidence. This view is fortified from the judgment of Hon'ble Supreme Court in Devarakonda Suryasesha Mani v Care Hospital, Institute of medical Sciences[4], wherein it was held as below:
"..2. Unless the appellants are able to establish before this Court any specific course of conduct suggesting a lack of due medical attention and care, it would not be possible for the Court to second-guess the medical judgment of the doctors on the line of medical treatment which was administered to the spouse of the first appellant. In the absence of any such material disclosing medical negligence, we find no justification to form a view at variance with the view which was taken by the NCDRC.
"Every death in an institutionalized environment of a hospital does not necessarily amount to medical negligence on a hypothetical assumption of lack of due medical care."
17. To sum up, relying upon the medical record, standard texts and the precedents of Hon'ble Apex Court, medical negligence is not attributable to the Opposite Parties. The Order of State Commission is upheld and the instant First Appeal is dismissed.
[1] Annals of International Medical and Dental Research, Vol (4), Issue (3) [2]MJMR, Vol. 31, No. 2, 2020, pages (241-245) [3] (1996) 2 SCC 634 [4] IV (2022) CPJ 7 (SC) ...................... DR. S.M. KANTIKAR PRESIDING MEMBER