State Consumer Disputes Redressal Commission
Dr. Jerin Joseph vs Josephantony on 7 January, 2010
BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI Present Hon'ble Thiru Justice M. THANIKACHALAM PRESIDENT THIRU Pon. GUNASEKARAN B.A.,B.L., MEMBER - I F.A.NO.730/2001 (Against order in O.P.No.116/1999 on the file of the DCDRF, Nagercoil) DATED THIS THE 7th DAY OF JANUARY 2010 Dr. Jerin Joseph W/o. Dr. Joseph Sahayam Sahayam Hospital Ganesapuram Road Nagercoil Appellants/ Opposite party Vs. JosephAntony S/o. Thopias Pillai Mela Manakudy Kanyakumari District Respondent/ Complainant The Respondent as complainant filed a complaint before the District Forum against the Appellant /opposite party praying for the direction to the opposite party to pay a sum of Rs.5,00,000/- towards compensation and Rs.3000/- as cost. The District Forum allowed the complaint and directed to refund Rs.3000/- and to pay Rs.120000/- as compensation and to pay Rs.40000/- and Rs.80000/-. Against the said impugned order, this appeal is preferred praying to set aside the order of the District Forum dt.26.6.2001 in CC No.116/1999. This petition coming before us for hearing finally on 24.11.2009. Upon hearing the arguments of the counsel for either parties, this commission made the following order: Counsel for the Appellant/ Opposite paty: M/s. Sudha Ramalingam, Advocates Counsel for the Respondents/ Complainant: Mr.V.Balaji, Advocate M. THANIKACHALAM J, PRESIDENT. 1.
The opposite party in OP.No.116/1999 on the file of the DCDRF, Nagercoil, having suffered an adverse order, has come to this commission for redressal, as appellant.
2. The respondent herein, as complainant, approached the District Forum, claiming a compensation of Rs.3,00,000/-, on the following grounds.
3. The petitioners wife, by name Mrs.Mary Jenivi, was admitted in the respondent nursing home, for delivery on 9/5/1998. She was taken to the operation theatre for caesarian, and at about 7.50 p.m, the opposite party, who came out, informed the petitioner that a male child was born, both mother and child are well. The petitioner was permitted to see the wife in the theatre, where she was found alright. All of a sudden, at about 11.00 p.m, the respondent conveyed to the petitioner, that she had reopened the stitch again and removed the uterus, which resulted in continuous bleeding, thereby the opposite party asked the petitioner to bring O Positive group blood immediately, though it was mid-night.
4. The petitioner procuring blood, reached the hospital on 10.5.98 at about 1 O Clock, in the early morning, where he found his wife was lying dead. Enquiry revealed that the respondent had removed the uterus of the petitioner wife, by subsequent operation and due to want of skill and incompetency on the part of the opposite party, his wife died and the reason is absolutely due to the negligence on the part of the opposite party.
The opposite party also failed to make pre-arrangement, to arrest the bleeding before conducting the operation.
They have also failed to secure blood, belonging to the patient group, which should be construed as worthless service. Even for the payment of Rs.3000/-, the opposite party has not issued regular receipt, intentionally amounting to irregular service. Though the wife of the petitioner died, in the hospital of the opposite party, they have dishonestly informed to the registering authority, as if death had taken place at Government Hospital, Nagercoil, thereby showing their malafide intention.
5. The opposite party had removed the uterus, by conducting second operation, without proper prior arrangement, causing continuous heavy bleeding, which would reveal the deficiency of service, for which they should be directed to pay a sum of Rs.3 lakhs as compensation, in addition to return of the amount by the opposite party.
6. The brief case of the appellant / opposite party, as seen from the written version:
The opposite party had not breached the duty of care owed to the patient and infact, she had exercised all reasonable care and skill, while treating the wife of the complainant, which cannot be termed, at any stretch of imagination, as deficiency in service, or below the standard of care or degree of care on her part.
The claim is made in the complaint, on false grounds with the sole object of grabbing money from the opposite party.
7. Mrs. Mary Jenevi, wife of the complainant was admitted at Sahayam Hospital on 9.5.1998 at about 11.00 a.m., with labour pain for third delivery. Clinical investigation revealed everything was normal. Her previous two child births were full terms and normal deliveries. After examination, the patient was shifted to labour room at 2.30 p.m, where after examination, administering necessary medicine at 3.30 p.m., Artificial Rupture of Membranes (ARM), was done. Further continuous examination revealed, at 6.30 p.m fetal distress for acute and fetal heart rate (FHR) was 160/minute, otherwise the patient was normal. In view of the FHR, opposite party decided to operate the patient for Lower Segment Caesarian Section (LSCS). The patient and the complainant were fully informed about the illness, necessity for LSCS, the alternatives for the proposed treatment, etc. Only after satisfying, explaining, with the consent, reserving a pint of compatible blood, belonging to O Positive, informed the surgeon Dr. Arunachalam, Anesthetist, Dr.A.Vasuginathan, who came to the hospital at about 7.00 p.m. They have also examined the patient, and satisfying the conditions, patient was taken to the operation theatre, and maintaining the body condition, LSCS was performed and Mrs.Mary Jenevi, delivered a live male child at 7.50 p.m.
8. From the operation theatre, the patient was transferred to the recovery room at 8.30 p.m., and examination showed, the uterus was well contracted, no bleeding per vagina, and necessary medicines were also given intravenously.
At 9.30 p.m, the patient, on per vaginal examination, showed bleeding, uterus was flabby and therefore immediately Dr.Indra Kumaravelu, Dr.Arunachalam, Dr.A. Vasuginathan, were informed to rush to the hospital immediately, meantime taking all necessary steps to stablise the patients vital parameter. Dr. Indra Kumaravelu, Dr. Arunachalam, examining the patient decided to perform hysterectomy, since the patient was going in for Post Portum Haemorrhage (PPH), which is an inherent risk of parturition. Noticing the condition of the patient, the complainant was informed about the same, explaining the necessary for the hysterectomy operation, shifting the patient to the operation theatre.
9. The abdomen was reopened through the same incision. After surgery, the patient was conscious, and other condition of the patient was also satisfactory. After surgery at about 11.20 p.m, when Mrs.Jenivi was examined, she was conscious, answered the question, and there was no vaginal bleedings. From operation theatre, the patient was shifted to ICU, connected to cardiac monitor, and oxymeter.
10. The conditions of Mrs. Jenivi, remained stable till 12.10 a.m, and suddenly she complained of chest pain, palpitation, sweating and breathlessness. Dr.J.L.Joseph Sahayam, physician, attended on her, necessary medicines were also administered. Despite all the emergency steps had been taken, and cardiac massage done, unfortunately at 12.20 a.m., she expired, and the efforts so far taken by the opposite party, ended in vain, for which she cannot be blamed, as if she had committed deficiency in service, or committed any medical negligence in taking care of the patient.
11. At any point of time, the doctors did not deviate from the established procedures as available in the clinical text books, and procedure adopted in these kind of cases. (In the written version, the steps taken then and there, and the standard protocol to be adopted as per the text, were also incorporated, which are not extracted here).
12. For the notice issued by the complainant, a reply notice was also given, explaining the reasons. In view of the above stated facts, it is incorrect to state, that the opposite party committed negligent act, or caused any deficiency in service, or removed the uterus of the patient, without informing the complainant. On the basis of the wrong information about the place of death of the patient, death certificate was issued, which was corrected later on. The sequences of events, which are incorporated in the case sheet of the patient, which are in accordance with the text book references, absolves the opposite party of any misdiagnosis, or error of judgement or not diagnosing anything vital, that lead to the later complication. The other averments, adverse against the opposite parties are denied, specifically praying for the dismissal of the complaint.
13. On the basis of the pleadings, after obtaining affidavits from the parties as well as from some of the doctors, who attended and relatives of the decided, then marking Ex.A1 to A15 and B1 to B6, as well cross examining one of the doctor, who attended the patient, the District Forum had come to the conclusion, that the opposite party has not treated the patient properly, according to the protocol, sufficient precautions were not taken to start the transfusion of blood early to avoid loss of blood of the patient, occurred in this case, that the patient was not attended between 8.30 p.m and 9.30 p.m, and that there was delay in running the emergency treatment, as contemplated in the text books of Obstetrics Gynecology. On the basis of the above conclusions, the District Forum further held that the opposite party had committed deficiency in service, as well medical negligence, and in this view, a direction came to be issued, to refund a sum of Rs.3000/- in addition to pay a sum of Rs.120000/- as compensation, as per the order dt.21.6.2001, which is under challenge.
14. Heard the learned counsel for appellant as well as the respondent, perused the written submissions, lower court records and the order passed by the District Forum also.
15. The complainant/ Respondent, admitted his wife for 3rd delivery, at the opposite party hospital on 9.5.98, at about 11.00 a.m. Considering the conditions of the baby, as well as the wife of the complainant, at about 6.40 p.m, or so, the opposite party had performed LSCS, in which the complainants wife delivered a male baby. After LSCS, the patient was examined by doctors attended on her, including the opposite party, found clinically normal, since pulse rate, blood pressure, cardio vascular system, and respiratory system, were normal. The continuous observation showed that uterus was well contracted, no bleeding per vagina. However at 9.30 p.m., there was variation in the pulse rate, and examination revealed, uterus was flabby, apprehending some problem. Doctors (experts), were also informed, rushed to the hospital, provided necessary treatment to the patient. Despite, the examination revealed that the patient was moving to Post Partum Haemorrhage, which is an inherent risk of parturition, and therefore in order to avoid the consequences of PPH, the opposite party and her team decided to perform hysterectomy, and accordingly at about 10.00 p.m., or so, informing the complainant and the patients relatives, leading to the necessity for hysterectomy operation, the abdomen was reopened, through the same incision was proceeded, and thereafter the patient showed very much improvement, since she was conscious. Pulse rate, blood pressure and everything was normal. Thus, satisfying further, there was no vaginal bleeding, necessary follow-up action was taken, monitoring the condition of the patient also. Till 12.30 a.m, on 10.5.1998, as reported by the opposite party, there was no problem, and in their words, the condition remained stable, till 12.30 a.m, on 10.5.1998. At that time, the patient complained of chest pain, palpitation, sweating and breathlessness and examination reveled fluctuations in the pulse rate, though abdomen was normal. The opposite party and her team of doctors, including Dr.J.L. Joseph Sahayam, physician, attended on the patient, took all measures, to resuscitate the patient, because of the inherent risk associated with parturition, which cannot be predicted. At 12.30 a.m, she expired and according to the opposite party, the cause for the death was cardio pulmonary arrest, which is in a way challenged, as if, because of the unnecessary second surgery, the patient died due to PPH.
16. The husband having lost the wife, though she had delivered a male baby, felt that the death was due to the careless act and negligence on the part of the opposite party, and therefore accusing her alone, not impleading other the doctors who attended on his wife, has filed the case, as stated above, in which he has also succeeded to certain extent, which caused grievance to the opposite party, and the findings of the District Forum are challenged, on various grounds.
17. It is the submission of the learned counsel for appellant that the wife of the complainant died not due to PPH, as held by the District Forum, whereas she died only due to pulmonary embolism, which is another inherent complication that follows child birth, it cannot be anticipated, though, to some extent, which can be anticipated under certain circumstances, which could not be prevented and in this way alone, she died, despite the best effort taken by the opposite party, and other doctors, where there is no negligence or carelessness of any kind, and this being the position, for the unfortunate death of the complainants wife, she cannot be mulcted with cost, as did by the District Forum.
18. The learned counsel for the respondent, opposing the above submissions of the appellant, would contend that LSCS, done in this case was totally unwarranted, which should be construed as negligence, that though it is the well laid down principle that no women shall die due to PPH, in this case it happened, because of the negligence on the part of the opposite party viz. that they have not injected Methorgin, which should have been administered at the time of delivery, not done so, even as per the documents relied on by the opposite party, that the doctors should have anticipated the PPH always, since in this case they have not anticipated, which resulted the death, which should be construed as deficiency in service, and negligence, that there was no necessity at all even as per the record of the opposite party, since there was no bleeding for the removal of uterus by performing hysterectomy, since it was done unnecessarily, it should be construed as negligence, leading to deficiency in service also, and that in order to cover-up the negligence on the part of the opposite parties, even they went to the extent of changing the place of death, and in this way, the place of death, though admittedly had taken place in the hospital of the opposite party, they have informed to the authorities concerned, as if, death had taken place in the Government Hospital, Nagercoil, and these things coupled with other attending circumstances, would certainly suggest that there was gross negligence, on the part of the opposite party, which was properly considered by the District Fourm, which requires only confirmation, not cancellation.
19. In order to understand the facts in issue, followed by the consequential things taken place, as well as to fix the liability, whether it is carelessness or negligence, as the case may, we have to understand certain medical terms, and in addition we have to remember, the dictum laid down by the Apex Court also, in respect of medical negligence, such as under what circumstances, an act of the doctor could be termed as medical negligence or carelessness, warranting tortious liability or under what circumstances when the doctor had followed the protocol as established, doctor can be relieved despite fatal had taken place, during the surgery or thereafter.
In addition, it is also to be remembered, that how the consent should be obtained and under what circumstances if the procedure is deviated or surgery is deviated, in order to save the patient, apart from consent, that could be recognized as informed consent, though the consent was necessary, since it may be very difficult, for the doctor at the time of performing the surgery to obtain, whose aim will be always to save the life, than thinking about getting the consent of the patient or getting the consent of the relatives of the patient, as the case may be at the crucial stage.
20. My learned predecessor, probably after hearing the case to some extent, in order to understand more about the PPH, summoned Dr.Saraswathi, Director in-charge, Institute of Obstetrics and Gynecology, Government Women and Children Hospital Egmore, and she was examined before this Commission on 5.4.2007.
Being an expert, not in dispute, she has given evidence regarding PPH, APH, how it happens, when happens, what are the drugs to be administered, surgical method to be followed, etc., not only by her experience, but also with reference to text books. For better appreciation, we feel the evidence given by her has to extracted as such:
Post-partum hemorrhage is a hemorrhage that occurs during the 3rd stage of labour and after delivery. When the hemorrhage occurs during the 3rd stage of labour, it is called 3rd stage hemorrhage. 3rd stage means stage of placental separation and expulsion. Thre is one entity called secondary PPH which occurs after 24 hours of delivery.
During normal delivery the expected amount of blood loss will be somewhere around 115 to 230 ML. If it goes beyond 500 ML, it is called PPH.
But according to our standard of women, even 300 ML loss is considered to be PPH in order to take prompt action.
The complications depend upon mainly on the pre-natal health condition of the individual. And even though it is said to be associated with certain pre-disposing factors, sometimes it occurs unexpectedly. So it is a real problem to the Obstetrician. 60% could be anticipated. The pre-disposing factors are anemia in the ante-natal period, over distressed uterus like twins, hydramnios, tumours like Fibroid complicating pregnancy etc. and APH, any anesthetic effect, certain anesthetic drugs, prolonged labour, mismanagement of third stage of labour, certain drugs. These are all causes of atonic PPH where the uterus is not contracting well after the delivery of the baby. There is another category called traumatic PPH, which may be due to any truma in the genetal tract. Another cause is due to some coagulopathy. These are 3 categories.
3rd stage of labour consists of (1) plancental separation (2) placental expulsion. Only after the signs of placental separation are established, we have to help her for placental expulsion. Some times, the attending person whether he may be a doctor or anybody, over enthusiastically they may try to deliver the placenta even before it separates, which may cause problem.
Unnecessary kneading of the uterus before the placenta is separated wil lead on to hemorrhage.
Active management of 3rd stage of labour will definitely bring down the amount of blood loss following delivery which are being followed now-a-days.
How does it happen?
If the pregnant women goes for labour to the same person with whom she was having her ante-natal check-up, the identification of the high risk factors wojld have been done by them and after categorizing the patient as a high risk and low risk, she or he would have decided the place of delivery. If she thinks it is beyond her capacity, it is also possible that sometimes the hospital also may not be capable, the patient would have been referred in time which will prevent the PPH.
Methods of arresting it:
Mechanical method we use to compress the uterus by massaging. Mechanical means manual also. In mechanical methos, tampons would be inserted.
(2) Drugs:
Oxytocics like Methyl Ergometrin, Oxytocin, Prostoglandin F2 Alpha, PGE1 tablet.
(3) Surgical method: If it is not conroled with all these drugs, we go in for surgical method in a step-wise manner.
First we put brace sutures-B Lunch suture, Uterine artery ligtion, with Ovarian artery ligation, we then go in for internal iliac ligation, and at last if she is not going to respond to all these, if she is a multi i.e., mother of many children, we also sometimes go in for hysterectomy i.e., removal of uterus in order to save the mother (Highlighted) First thing is that we have to give blood in time, some times we may have to give blood products also. We have to take all measures to maintain her general condition.
If blood is not readily available?
In case blood is not able to be obtained, what should be done?
If the blood is not available, if they have the facility of giving Haemocele, it can be given only for time gaining and the patient has to be refered to higher institution where blood is available.
What text books say is that you should anticipate PPH in 100% of cases. In my view, practically it is not possible to anticipate all case of PPH.
Now a days, it is being instructed to give Oxytocics at the time of delivery of the anterior shoulder of the baby to prevent the blood loss to a minimum. Especially in cases where you anticipate PPH (over distended uterus, anemia without failure) we definitely follow this i.e., giving of Oxytocics at the time of delivery of the anterior shoulder of the baby.
Does every maternity centre have to be equipped with blood facility and man power?
It is always better to have it.
Keeping this in mind, recently our Govt. has come with the concept of setting CEmONC Centres i.e., Comprehensive Emergency Obstetric and Neonatal Care throughout our Stae which will have 24 hour facility for delivery. Caesarian and neonatal care.
It is not in normal practice to do BT, CT for all (bleding time and clotting time). But now a days it is being done by most of the doctors. It is always advisable to conduct BT, CT values may not be always the same. Sometimes, it can change at a later stge in certain conditions like excessive bleeding.
21. In this case, the cause of death is not very much challenged, though in the written submission, it is stated that PPH had caused, because of the failure of non-anticipation by the doctors. It is also the case of the learned counsel for the complainant that basically LSCS was not at all necessary, since there was no fetal distress, as contended by the opposite party, which alone lead to other complications, and in this way primarily it should be held that the opposite party had performed unnecessary caesarian operation, that too, when the wife of the complainant had normal delivery previously, not having any complications. In this context, to understand further, in addition to explanation given by Dr. Saraswathi, we have to see, what the literature says.
22. In the text book of Obstetrics by D.C.Dutta,, Fourth Edition 1998, under the heading To note the fetal well being it is stated that Fetal Heart Rate (FHR) alongwith its rhythm and intensity should be noted every half hour in the initial phase and every 15 minutes in second stage or following rupture of the membranes.
To be of value, the observation should be made during and following uterine contraction. The count should be made for 30 seconds. For routine clinical observation, ordinary stethoscope is quite suitable. Doppler ultrasonic cardiography (Dopplex) however is not only helpful in the case of obesity and polyhydramnios but if carefully performed gives meaningful information like those obtained by the most sophisticated monitoring techniques.
Normal fetal heart rate ranges from 110-150 per minute. (Highlited)
23. Fetal distress is explained as Fetal distress is an ill defined term, used to express intrauterine fetal jeopardy, a result of intrauterine fetal hypoxia, it is clinically manifested by changes in rate, rhythm and quality of fetal heart rate and other biochemical events. It must be emphasized that hypoxia and acidosis is the ultimate result of the many causes of intrauterine fetal compromise
24. In case, if fetal distress is not properly monitored, an appropriate steps had not been taken, what would be the result is given under heading Patho-physiology, and the relevant portion reads A continuous severe oxygen deprivation may cause stillbirth. In less severe cases, the baby may be born with a low Apgar score. There ma be a variable degree of brain cell damage which in the log run may produce mental retardation.
How this kind of distress should be managed, during pregnancy, during labour, and what steps should be taken to improve uterine blood flow are given in the same book at page 655, and the relevant portion, during labour, is extracted hereunder, which reads:
When the diagnosis of fetal distress established by continuous cardiographic tracing supplemented with fetal scalp blood estimation, the baby should be delivered urgently by the safest route vaginal or abdominal. In the absence of continuous monitoring facilities, deterioration in the FHR pattern and presence of micconium stained liquor dietates an urgent delivery.
25. On the other hand it is the submission of the learned counsel for respondent, that normal fetal heart rate may vary between 110 and 160 beats per minute, and therefore if it had not exceeded 160 beats per minute, there is no necessity to do LSCS, and in this case, even according to the case sheet, the heart rate had not exceeded 160 beats per minute, and therefore LSCS undertaken is unwarranted. In support of the above submission, ACOG Education Pamphlet AP015-Fetal heart Rate Monitoring During Labor, a print out taken from online is produced, which says It is normal for a fetal heart rate to vary between 110 and 160 beats a minute. This is much faster than your own heart rate, which is about 60-100 beats per minute. A heart rate in your baby that does not vary or is too low or too high may signal a problem.
Changes in the fetal heart rate that occur alongwith contractions form a pattern.
Certain changes in this pattern may suggest a problem.
26. On the basis of the above literature, the fetal distress, advanced on the side of the appellant is challenged. By going through the recognized text, as relied on by the learned counsel for the appellant, as quoted above, it may not be safe, to rely on the printout, produced by the complainant and even assuming it is correct, it is the decision of the doctor, who is the judge to take a decision at the appropriate time, to decide whether LSCS was required in order to save the child or not, and in this view, in this case LSCS was successfully done, a live baby was taken out, though cry was not noted in the case sheet or not, which alone cannot be taken as negligence or deficiency in service, that too in this case, since there is no complication for the baby.
27. Clinical Obstetrics by Mudaliar and Menons, gives us bird view regarding Antepartum hemorrhage, Postpartum hemorrhage, Causes of Maternal Mortality, Complications of the 3rd stage of labour, where Postpartum Hemorrhage generally occur, and under what circumstances Hysterectomy is the definite treatment of persistant uterine atony. According to this book Antepartum Hemorrhage is defined as from the genital tract after then 28th week of pregnancy and before delivery.
Causes: A pregnant woman may bleed due to causes associated with pregnancy or occasionally due to coincidental factors unrelated to pregnancy.
. Premature separation of placenta or abruption placentae . Placenta previa or bleeding from an abnormally situated placenta . Circumvallate placenta . Rupture of the marginal sinus of the placenta . Vasa previa which we are not verymuch concerned, in this case, and it is quoted for better understanding. The PPH, coupled with Coagulopathy may be fatal, which is an established one and as submitted, it is a night mare even today, for the doctors.
28. In the same book at page 277, under the chapter complications of the 3rd labour, we find the following:
The complications encountered in the third stage of labour are:
1.
Postpartum hemorrhage
2. Retained placenta
3. Uterine inversion POSTPARTUM HEMORRHAGE Definition Hemorrhage occurring after the delivery of the baby is termed postpartum hemorrhage (PPH). Hemorrhage occurring within 24 hours of delivery is termed Primary Postpartum hemorrhage and that occurring any time after 24 hours of delivery is called secondary postpartum hemorrhage.
PRIMARY POSTPARTUM HEMORHAGE Primary postpartum hemorrhage is defined as loss of 500 ml o more of blood occurring within 24 hours of delivery of the baby. Its incidence is about 5% of deliveries. This definition, while satisfactory from the point of view of obtaining comparative statistics, is not wholly acceptable from the clinical point of view.
The main causes of primary postpartum hemorrhage are . Uterine atony . Genital tract trauma . Retained placental fragments . Coagulatin disorders There are two varieties of primary postpartum hemorrhage
1. Atonic:
Atonic hemorrhage is from the placental site and is due to the failure of the uterus to adequately conract and retract.
29. It is also the established principle that during the labour management, every attempt must be made to prevent or anticipate PPH, and that is why it is followed as of rule, immediately after delivery or just at the time of the delivery of the baby, Methergine injection should be injected, and the failure should be construed as negligence, which is one of the defense raised by the learned counsel for the complainant, as if this was not done, by the opposite party, and on that basis, a seal of negligence should be affixed on them, which we will discuss at appropriate stage.
30. Effective management, Curative Treatment are contemplated, as under
object of treatment is to replace the blood lost and to stop the bleeding Repacement of lost blood: Atleast two large bore intravenous cannulas preferably 14 gayge, should be inserted. Blood should be drawn from crossmatching, estimation of hemoglobin, packed cell volume, coagulation tests, baseline urea and electrolytes. Fluid replacement should be commenced immediately. Blood transfusion should be started as soon as possible.
If the hemorrhage is still found to persist (in a small minority), traumatic factors must be considered. If tears of the cervix of vagina are found, they must be sutured. In their absence, with persistent bleeding, the management of these presents a problem. Intrauterine packing has been advocated by some. Coagulation failure may be a factor in some cases.
When bleeding continues inspite of all these, the obstetrician has to consider hysterectomy. Hysterectomy is the definitive treatment of persistent uterine atony.
31 Practical Obstetric Problems by Ian Donald, Sixth edition, the ways and means for the management of PPH is given and in the case APH, what could be done is the given at page 613 as under Management of Atonic Postpartum Hemorrhage: Resuscitation must start immediately and simultaneously while the cause of bleeding is being sought and specific treatment instituted. As a general rule, two wide bore intravenous canulae must be sited and fluids transfused to maintained the blood volume. Blood should be sent for cross-match and atleast 4-6 units of red blood cells and fresh frozen plasma must be arranged.
Pending the arrival of cross-matched blood, normal saline and plasma expanders (gelatins, dextrans, and hydroxyethyl starches, albumin) shoud be given to maintain blood pressure, because failure to maintain intravascular volume leads to renal shut down and irreversible shock. Oxygen by mask is given. Baseline investigations required include haemoglobin, haematocrit, coagulation profile, D-dimer, urea and electrolytes. A urinary catheter is important to maintain hourly urinary output. Other parameters which need to be monitored include pulse and blood pressure every 15 minutes, and oxygen saturation by a pulse oximeter.
32. As quoted in the Manual Of Practical Medicine by R. Alagappan, Ninety percent of death occur within the first hour even before a diagnostic theraphy plan is implemented
33. In the case on hand we are more concerned about the pulmonary embolism, since this is the cause of death of the patient and not PPH, though it had occurred according to the opposite party, successfully arrested, but leading to other complications, and in this way, even it could be said that PPH caused pulmonary embolism.
34. Text book of medicine by Cecil, Edited by J.Claude Bennett, M.D., at page 422 under the heading Pulmonary Embolism, Robert M.Senior, it is said:-
Pulmonary embolism is the impaction of material into branches of the pulmonary arterial bed. Although they may completely prevent blood flow, most pulmonary emboli do not produce necrosis of lung parenchyma (pulmonary infarction) because (1) a dual circulation (Bronchial and pulmonary) supports lung parenchumal tissue and (2) exchange of oxygen and carbon dioxide can occur directy between the tissue and alveolar gas. Most pulmonary emboli are blood clots (thromboemboli); more rarely, neoplastic cells, fat droplets air bubbles, exogenous materials or pieces of intravenous catheters and catheter introducers occlude pulmonary vessels. The ensuing discussion deals with pulmonary thromboembolism.
35. In the same text under the heading Risk Factors for Deep Venous Thrombosis and Pulmonary Thromboembolism it is said that Pregnancy, especially in the puer-perium and after caesarean section, it is the case we are dealing. Statistics also reveals, world wide Pulmonary Embolism is estimated to cause two lakhs death each year, even in the advanced country US, and it is the 3rd leading cause of death among hospitalized patients.
36. Having the above medical knowledge to some extent, now we have to see the legal position.
37. The Apex Court of the land, in the celebrated case Jacob Mathew Vs. State of Punjab & Another, reported in (2005) 6 SCC 1, has held that it should be shown that the doctor against whom a medical negligence is attributed, did something or failed to do something, which in the given facts and circumstances, no medical professional in his ordinary sense, and prudence would have done or failed to do, and that the death should be the direct result of negligent act of the doctor, and the act alleged must be the proximate and efficient cause without the intervention of any other negligence, and in this kind of cases alone a doctor could be held responsible, warranting tortious liability, which is also reiterated in Nizam Institute of Mdical Sciences Vs. Prsanth S.Dhananka & Others, reported in 2009-4-LW Part 1, and followed in Martin F.D.Souza Vs. Mohd. Ishfaq reported in AIR 2009 Supreme Court 2049, wherein it is said A medical practitioner is not liable to be held negligent simply because things went wrong from mischance or misadventure or through an error of judgement in choosing one reasonable course of treatment in preference to another. He would be liable only where his conduct feel below that of the standards of a reasonably competent practitioner in his field. . It is further observed that an error of judgement may or may not be negligent. It depends on the nature of the error , further concluding The standard of care has to be judged in the light of knowledge available at the time of the incident and not at the date of the trial. Also, where the charge of negligence is of failure to use some particular equipment, the charge would fail if the equipment was not generally available at that point of time.
38. It is also the dictum of the Apex Court that Negligence in the context of the medical profession necessarily calls for a treatment with a difference. To infer rashness or negligence on the part of a professional, in particular a doctor, additional considerations apply. A case of occupational negligence is different from one of professional negligence. A simple lack of care, an error of judgement or an accident, is not proof of negligence on the part of a medical professional. So long as a doctor follows a practice acceptable to the medical profession of that day, he cannot be held liable for negligence merely because a better alternative course or method of treatment was also available or simply because a more skilled doctor would not have chosen to follow or resort to that practice or procedure which the accused followed. When it comes to the failure of taking precautions, what has to be seen is whether those precautions were taken which the ordinary experience of men has found to be sufficient; a failure to use special or extraordinary precautions which might have prevented the particular happening cannot be the standard for judging the alleged negligence. So also, the standard of care, while assessing the practice as adopted, is judged in the light of knowledge available at the time of the incident, and not at the date of trial. Similarly, when the charge of negligence arises out of failure to use some particular equipment, the charge would fail if the equipment was not generally available at that particular time (that is, the time of the incident) at which it is suggested it should have been used.
39. In Postgraduate Institute of Medical Educational and Research, Chandigarh Vs. Jaspal Singh and Others, the Apex Court reiterated the settled position regarding, the professional negligence which reads It is now well settled that a professional may be held liable for negligence if he was not possessed of the requisite skill which he professed to have possessed or, he did not exercise, with reasonable competence in the given case the skill which he did possess. It is equally well settled that the standard to be applied for judging whether the person charged has been negligent or not; would be that of an ordinary person exercising skill in that profession. It is not necessary for every professional to possess the highest level of expertise in that branch which he practices. Then coming to the burden of proof, it is the dictum of the Apex Court that In the medical negligence actions, the burden is on the claimant to prove breach of duty, injury and causation. The injury must be sufficiently proximate to the medical practitioners breach of duty. On the basis of the above settled proposition of law, the evidence in the present case has to be evaluated, when it is specifically alleged by the complainant, that the opposite party has committed lack of care and cautions and the neglect on the part of attending doctor.
40. Having the above settled principle of law, and the information regarding the treatment, it should be now fit in with the facts and circumstances of the cases, in order to fix the liability, either to affix the medical negligence or to erase the medical negligence, which is alleged.
41. It is an accepted principle, even as ruled by the Apex Court, as indicated above, the burden (though initial) is upon the complainant to plead and prove the medical negligence, though pleading need not be construed so strictly, that does not mean that there should be no plea at all, attributing medical negligence. By going through the pleadings in this case, we are yet to know what is the actual medical negligence attributed against the opposite party, or the team of doctors, who performed the surgery in this case, though they are not impleaded. As seen form paragraph 11, incompetency on the part of the opposite party is pleaded, para 12 pleads prior arrangement to arrest the bleeding not made, para 13 says- worthless service, naming so, para-14 says, intentionally receipts not given and para 15 says death place wantonly given incorrectly in order to evade liabilities. Nowhere, it is said even after the reply, after the perusal of the case sheet, the doctors who have attended the patient, whether competent person, skilled person or not, which procedure they failed to follow, which protocol as catalogued in the text, was violated etc., Therefore, based upon the pleadings, there is nothing wrong in saying, that the complainant failed to plead specific instance, attributing medical negligence, and in this view, it should fail, which was not properly considered by the District Forum.
42. In a case of medical negligence to prove so, where expert opinion is necessary, the non-examination of expert witness must be fatal. The complainant, who has filed affidavit, admittedly is not an expert, and in fact he said nothing, except repeating the petition, in the affidavit, failing to pinpoint the alleged medical negligence. Therefore, we would say empathetically, that the complainant failed to discharge even the initial burden of proving the medical negligence , which should follow no burden is shifted to the opposite party, to disprove the case of the complainant. This fact is also not properly considered by the District Forum, probably on the basis of surmise and conjuncture, which are not warranted, has come to the conclusion that by the negligence or the deficiency caused by the opposite party death would have occurred, thereby ordering compensation, which is in our considered opinion not legally sound, requiring seal of approval by this Commission, being the appellate authority.
43. We are conscious of the fact, that the complainant though failed to examine the expert witness on his side, still can prove the case from the admitted facts, as well even from the records produced by the opposite party. In this way, alone an attempt was made to establish, that the doctors have failed in their duty and that should be construed as medical negligence or deficiency in service.
44. It is the common case of the parties that the complainants wife died in the hospital of the opposite party. But unfortunately, it is not known on whose instruction, the death place was noted, as if, had happened, at Government Hospital, Nagercoil, patently incorrect. It is the submission of the learned counsel for complainant, that in order to cover the misdeeds or negligence, this kind of document was created, appears to be unacceptable, since the fact cannot be screened forever, that too in this case, when it is an admitted fact that the complainants wife was admitted in the opposite party hospital, where surgeries were performed.
When the opposite party came to know about the mistake entry, entered in the death register, approaching-addressing the authority concerned, had corrected the same, and therefore on the basis, as if the opposite party had reported that death had taken place at Government Hospital, Nagercoil, we are unable to attribute negligence on the part of the opposite party, so as to compensate the complainant or redress his grievance.
45. As seen from the written version, LSCS was done by Dr. Arunachalam, M.S., Surgeon, in co-ordination with Dr. Vasuki Nathan, Anesthetist. It is the further case of the opposite party that Dr. Indra Kumaravelu, M.D.,DGO., Dr. Arunachalam, M.S., Dr.Vasukinathan, M.D.D.A., performed hysterectomy, considering the conditions of the patient, and later on Dr.J.L.Joseph Sahayam, physician, attended at 12.12 a.m., and despite their best effort, to revive the patient, unfortunately patient died at 12.30 a.m. It is not the case of the complainant before the District Forum or before us, the above said doctors are unqualified, or unskilled or incapable of performing any surgery or they did not perform the surgery, whereas the opposite party alone, did all these things, leading to death. All the above said persons, have filed affidavits in support of the opposite party, informing the For a, that under what circumstances, LSCS was performed, hysterectomy was performed, and how the patient developed pulmonary embolism, leading to death etc. We find no reason to ignore those affidavits, which are admissible, which were unfortunately not at all read and analysed by the District Forum, and the reasons are unknown. The questionnaire was issued to Dr.Indra Kumaravelu, who attended the patient, by the complainants advocates, seeking information, for which reply is given as follows:
1. Whether you had gone to the Sahayam Hospital on 9.5.99?
Ans: YES
30. Whether you had decided to remove the uterus?
Ans:
NO
46. Even after the answer, it is not the case of the complainant, that Dr.Indirakumaravelu, has not attended the patient, whereas the opposite party, as an after thought, brought her name to screen the misdeeds or something like that. Therefore, in the absence of any positive evidence, leave alone the expert evidence, the affidavits given by the above said doctors, should have its due weight, in assessing the medical negligence. By going through the affidavits, we are unable to find out any elements of untruth, either intrinsically or otherwise, to eschew the same as unworthy of acceptance, whereas, we find much support form those affidavits, that all the doctors, including the opposite party, have made all arrangements, that are necessary for the delivery, as well as for solving the consequential problems. In this case, the PPH was arrested by hysterectomy, which is the best treatment, as pointed out in the text, which was not the cause of the death also.
47. Ex.B1 is the inpatient chart, regarding the wife of the complainants wife, commencing from 9.5.98 - 11.00 a.m till 10.5.98, at 12.30 a.m . A feeble attempt was made to say that after the notice, this documents was fabricated or prepared, and by going through the documents, including the handwritten Xerox copy, as well as the typed set, we are unable to say so. It is the usual practice of a person, who suffered, blaming the doctors that the doctors failed to perform their duty properly, if documents produced as such, complaining it as a concocted one, and if not produced, blaming that they failed to maintain the documents properly, for which we cannot find answer always. Ex.B1 was not shown to our satisfaction, as one prepared for the occasion, to suit the case, thereby to cover or eclipse the medical negligence, said to have been committed by the opposite parties. As seen from Ex.B1, from the time of admission, the condition of the patient is noted, and the treatment given also catalogued including the doctors, who attended at appropriate time. As seen from the entry, at about 7.00 p.m. or so, it was decided to perform LSCS and the anesthetist Dr.Vasukinathan, also assessed the condition of the patient. In this context, we have to see why instead of allowing normal delivery, caesarian was decided, which is faulted.
48. The entry in the case sheet at 5.30 p.m, would indicate, that uterine was contracting and FHR was 130 per minute, PV admitting four fingers. At 6.30 p.m., doctors have noticed pre-abdominal contractions, and FHR was 160 p.m, in addition to Liquor Mac stained, also noticed Foetal distress.
Despite Artificial Rupture of Membrane (ARM) was done, there was no normal delivery, and the foetus heart rate was noticed, on the high side. As pointed out by us, placing reliance upon the text, it is the case of the appellant, that the doctors came to the conclusion that there was foetal distress, which may cause problem to the baby, and therefore they have decided to perform LSCS. Though, this process was questioned, since FHR 160 may not be a dangerous position, we are unable to accept the same, and in the decision taken by the doctors, there cannot be any negligence or violation of the protocol, since in the judgement of the doctors, the variation would affect the baby, if not delivered.
In this view, the decision taken by the doctors, as per the affidavit, to perform LSCS is fully justifiable, and therefore, it cannot be stated as an unwarranted one, leading to other complications. After LSCS, under anesthesia, admittedly a live male baby was delivered, the placenta was removed, the uterus was found contracted, and therefore, according to opposite party, which is supported by the affidavits also, abdomen was closed in layers, after perfect haemostatic, which we found in the case sheet itself.
49. It is the routine procedure, not in dispute that Methergine injection should be injected, when the baby comes out, and it is the case of the opposite party also, that they have injected, which is disputed. As rightly pointed out by the learned counsel for the complainant/ respondent, we find no such entry regarding Methergine injection given in the chart at the time of the delivery, which is mandate. On the basis of the entry, not available at the appropriate time, the learned counsel Mr.V. Balaji, appearing for the respondent, urged that it is a clear violation of protocol or in other words by their negligent act, they failed to inject Merhergine, which alone had complicated, later leading to PPH, followed by hysterectomy.
50. The Doctor, who performed LSCS was cross examined, regarding this aspect. He had admitted that in the prescription or the noting, he has not prescribed Methergine injection and at the same time, he would state that Methergine was given by anesthetist. But, as seen from the affidavit of Dr. Vasuginathan, it is not his case that he prescribed Methergine injection. Thus, we find some inconsistency, how Methergine injection was given by whom, or whether it was not given at all. As an answer to this accusation, Dr.Suresh, who is defending the appellant, invited our attention to the nursing record, wherein we find an entry at 7.50 p.m that Live male baby delivered Inj.
Methergine 2 Amp IV given.
After placenta was taken Inj.
Oxytocin 2 amps IV + DNS.
Thus according to the opposite party, the mandatory injection was injected, and there is no negligence. This also sought to be explained by Mr.V. Balaji, that nursing record is one maintained in the ward, which will not prove that Methergine injection was given in the operation theatre, at the time of delivery and therefore this will not serve the purpose. True, meticulously this is not done, but it is the usual practice of every trained nurse, even without the prescription by the doctor, as a mandate, to inject Methergine, and in this way, as noted in the nursing record, whether it was maintained in the OT, or elsewhere, it is proved, immediately after delivery, Methergine injection was given, and therefore on this score, we are unable to fix any culpability or negligence.
51. In Ex.B1, after the entry, LSCS, we find no entry in the nursing record between 8.30 p.m and 9.30 p.m. Therefore, it is the submission of the learned counsel for the complainant that there was no proper nursing care or even monitoring for one hour, which should have aggravated the situation, dropping the BP, as noted at 9.30 p.m in the inpatient chart which should be construed as gross negligence. Tough there is no entry in the nursing record, as seen from inpatient record, there was continuous monitoring between 8.30 p.m. and 9.00 p.m, then 9.30 p.m, where we find the notings indicating that the patient was normal, since it is stated in the entry at 8.30 p.m. uterus well contracted, no bleeding PV, transferred the patient to recovery room. Then in the entry at 9.00 p.m., we find the following:
P/R -
84 /mt.
BP - 120/80 mmHg.
CVS RS NAD PA Uterus well contracted No bleeding PV, thereby showing nothing happened unusually.
Probably in the process of taking patient from operation theatre to recovery room, then to the normal ward, the entry might have been omitted, between 8.30 p.m and 9.30 p.m. When materials are available, that the patient was under the constant care of the hospital, as indicated in the inpatient record, we cannot presume or construe that there was deficiency or negligence in taking care of the patient, as if, which might have lead into the subsequent complications, for which, as indicated above, there is no expert opinion also.
52. At 9.30 p.m., doctors have noticed the following symptoms P/R -
120 / mt BP -
90/60 mmHg RR -
38/mt O2 IV line 2 RI-I DNS-1 PA UT flabby uterus massage done Bleeding PV + OS opened Blood clots removed + Surgeon , anesthetist, Dr.Indira Kumaravel Informed for which, management was taken as indicated, which says IV line 3 Haemaceal 1 Blood 1 Inj.
Methergine 2 Amp IV Inj.
Syntocinon 4 Amp in drip Inj.Syntocinon 4 amp in line II Inj.
Prostodin 2 Amp IM Inj.
Perinorm 1 cc 1M Inj. Mephentine 1 cc IV Inj. Efcorlin 2 vials Inj. Dopamine 2 amp in DNS 1 pint drops/ min\ From 9.30 p.m onwards, there was continuous monitoring of the patient, and the patient was also conscious, answering the question and it may be useful to extract the entries as such in order to understand the condition of the patient and what kind of treatment was given, and how a decision came to be taken, in order to perform hysterectomy, and the relevant notes are :
9.45 PM BP -
80/50 mmHg. Foot end elevated interine massage done P/R -120/mt.
RR -32/mt.
Anxious CVS Tachycardia+ S1 S2 Heard RS clear PA- UT flabby PV-
Bleeding S/b.
Dr.Arunchalam 9.45 PM Pt. G.C P/R 120/mt.
Tachycardia + Patient is anaemic Patient is suffering PPH. So we have decided to go for Abd. Hysterectomy operation 9.45 PM S/b. Dr. Indira Kumaravel Call to see a case of Atonic PPH. LSCS done at 7.15 PM, Medical Line of management like Inj. Oxytocin 40 units Methergine 4 mg.
Inj. Prostoglandin 2 amps Uterine massage given On Examination : Patient conscious. Answering questions P/R 120/mt PA - Uterus Flabby Bleeding PV+ Uterine massage done Clots removed Clotting time 6 to 7 min Hysterectomy To get the opinion from anesthetist At 9.45 p.m., Anesthetist Dr. Vasuginathan, had seen the patient, in addition Dr.J.L. Joseph Sahayam, also examined and found the patient was conscious oriented, though on examination of abdomen, they felt uterus flabby. Once again 9.55 p.m. Mrs. Vasuginathan, examined the patient, probably came to the conclusion that the patient was fit for surgery under GA. For the above facts also, we find necessary entries in the case sheet, between 9.45 p.m. and 10.00 p.m. Thus, considering the condition of the patient, having decided to go for hysterectomy, the surgeon Dr. Indira Kumaravelu was summoned and the said surgeon also concurring, with the assistance of Dr.Arunachalam and Mrs. Vasuginathan, reopened the abdomen, through the same incision they did the abdominal hysterectomy, then the abdomen was closed in layers between 10.00 p.m and 10.45 p.m. Simultaneously, one bottle of blood was given and necessary medicines were also injected or given, then it is seen pulse rate was 110 per minute and BP was 110/70 p.m.
53. After the surgery, it was also noted that no bleeding per vagina, and the blood flow continued. Because of the above sincere efforts taken by the team of doctors at 11.20 p.m. as seen from the inpatient record, patient regained consciousness, she was answering the questions and her pulse rate was 112/mt. and he BP was 110/70 mmHg further disclosing, no vaginal bleeding. Therefore, it is made out by the opposite parties, that not only by producing the inpatient record, but also by filing the affidavits of the concerned doctors, as available in the records, that when they have noticed the condition of the patient deteriorating, causing bleeding, they took the necessary curative steps, which is a standard and certain one viz. Hysterectomy and by that they have also arrested the bleeding, thus satisfying a prudent doctors work in attending the patient, whose life was in risk, in the table of operation theatre.
54. The learned counsel for complainant questioning the hysterectomy operation itself, as if it was unnecessary, drew our attention to the case sheet itself, where we find no specific indication, who had taken the final decision of performing hysterectomy, since there is no entry at 9.45 p.m about the decision taken, in the sense, who took the same though there is an indication that it was decided to perform hysterectomy. In this context the answer given by Dr.Indirakumaravelu was brought to our notice, as well as the affidavit filed by her also. As indicated by us supra, when Dr.Indirakumaravelu was questioned, whether she had gone to the opposite party hospital on 9.5.98, she answered Yes, and for the question, whether she had decided to remove the uterus, her answer was No. On the basis of this answer, a feeble attempt was made as if the opposite party alone had taken decision, which was unwarranted and lateron the support of other doctor was sought for. In this view, we are unable to concur, since the decision taken while treating the patient, must be a joint decision, and probably in this sense alone Dr. Indirakumaravelu, had stated when she was questioned, which is also explained by her, in the affidavit dt.24.5.00, while narrating what had happened on 9.5.98 night from 9.30 p.m in the hospital, how she had been there, how she was summoned and how she had examined Mrs.Jenivi and noticed the suffering of the patient from PPH. She has also further stated, that it was decided by the doctors, assembled there, hysterectomy was the only solution to stop the bleeding, in order to save the life of the patient. She had further asserted in the affidavit, that accordingly, herself and Dr. Arunachalam, proceeded to perform hysterectomy and at that time Dr.Shareen Joseph was also available to help and anesthesia was given by Dr.A. Vasuginathan.
She has also explained in the last paragraph of the affidavit, under what circumstances she said No for the query which says:
This is the reason why I had to say No when the complainant in his lawyer notice asked me whether I took the decision to remove the uterus of the patient. When it is a decision taken by a team of doctors. I could not say that I alone took the decision to remove the uterus of the patient.
We find no reason, to discard the solemn statement of Dr.Indirakumaravelu, who is a qualified Gynecologist, working as consultant obstetrician and gynecologist. In support of the above affidavits, other doctors have also filed affidavits.
55. Dr. Arunachalam, has given a detailed account in the affidavit about the LSCS, performed, and having satisfied that the operation was perfectly completed, according to him, he went to the house at about 9.00 p.m. He would further state, that when she had seen the patient on 9.45 p.m., due to bleeding the condition of the patient was serious and at the same time Dr. Indirakumaravel, also reached who did the hysterectomy, for which he assisted. Similarly, Dr. Vasuginathan also filed an affidavit under what circumstances, they have jointly compelled to take the decision for hysterectomy, which was performed successfully also, thereby controlling the bleeding. In the hysterectomy operation performed by Dr. Indirakumaravelu, assisted by other doctors, by going through the case sheet, as well as the established procedure as pointed out by placing reliance upon the text, we are unable to see any deviation or medical negligence or any act they did, so as to say unwantedly or without any cause. In fact in order to save the life of the patient, who was bleeding after delivery, which is the inherent risk available in the case of delivery, as admitted, the opposite party and other doctors have jointly did their best, and at that stage, saved the patient, and therefore in performing hysterectomy, which is the definite treatment of persistent uterine atony and which is the ultimate management for controlling of the bleeding. In this view, in the absence of any contra evidence, we are unable to find fault, with the opposite party, in the treatment given by them.
56. Though the opposite party succeeded in arresting the PPH, complication followed at 12.10 a.m., i.e. on 10.5.98, since the patient complained chest pain, palpitation, breathlessness showing sweating also. Immediate examination revealed pulse rate fluctuating, BP also was not normal, indicating some seriousness and immediately physician, surgeon and anesthetist were informed, simultaneously relatives were also informed. The complainant who is the husband, pleaded ignorance in the complaint, regarding the treatment given by the opposite party and he would state, he was asked to get blood and after purchasing blood, when he came, he had seen his wife in the death bed, which may not be correct, to the entire extent. It is not the case of the opposite party, that they have informed the complainant alone, whereas they have informed the relatives, which is supported by the affidavits filed by mother, sister, and father of the patient. They have also stated, that they have given consent, which should be construed in this case as, informed consent, though positive consent was not obtained, before hysterectomy operation. It is the case of the opposite party also, that the patient was conscious, but they were unable to get the signature of the patients, since in both the hands intravenous injections were fixed. All the relatives of the patient, supported the doctor. If certainly, the opposite party had committed any deficiency or negligence, they would not have allowed the opposite party, to go so freely. Since they have supported also, we are of the view that there was no negligence on the part of the opposite party, and that is why they have supported the opposite party, in which we cannot find any fault.
57. As proved by the affidavits, at 12.12.a.m, Dr.Joseph Sahayam, examined the patient and noted that patient find it difficult in breathing, for which also medicines were administered and despite the RR reduced, BP also fluctuating, all the possible treatments are given till 12.20 a.m, which time they have noticed massive pulmonary embolism, indicating about the absence of pulse, BP, respiratory etc., and it continued. The best effort taken to resuscitation, they were unable to revive the patient and ultimately the destiny overruled the doctors, ending the life of Mrs.Jenivi at 12.30 a.m.
58. The nursing record maintained and vital parameters maintained would indicate that there was continuous and constant care, not only in giving blood, whenever required but also supplied oxygen, in addition to giving injection, including the period 7.45 p.m to 9.30 p.m, All the above treatment, recorded in Ex.B1, are in confirmity with the medical science, and we are unable to find any deviation, and deviation said to have been committed are of flimsy in nature, and if at all maximum, it can be said only error, not to be construed, as medical negligence. The District Forum, without properly analyzing the medical records, and understanding the medical problems, have erroneously come to the conclusion, as if the opposite party had committed medical negligence, not acceptable to us, and therefore the same is liable to be set aside.
59. In the result, the appeal is allowed, setting aside the order of the District Forum in O.P.No.116/99 dt.21.6.2001, and the complaint is dismissed. Under the facts and circumstances of the case, there will be no order as to cost in the appeal.
PON GUNASEKARAN M. THANIKACHALAM MEMBER-I PRESIDENT INDEX : YES / NO Rsh/d/mtj/Medical-PPH