State Consumer Disputes Redressal Commission
Dr. Surendra Mohan Tripathi vs Sri Ganga Ram Kolmet Hospital on 19 January, 2024
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/1/2017 ( Date of Filing : 02 Jan 2017 ) 1. Dr. Surendra Mohan Tripathi S/O Late Sri Gomti Prasad Tripathi R/OHouse No. 165 Civil Lines Bahraich City Post And Distt. Bahraich ...........Complainant(s) Versus 1. Sri Ganga Ram Kolmet Hospital New Delhi ............Opp.Party(s) BEFORE: HON'BLE MR. Rajendra Singh PRESIDING MEMBER HON'BLE MR. Vikas Saxena JUDICIAL MEMBER PRESENT: Dated : 19 Jan 2024 Final Order / Judgement Reserved State Consumer Disputes Redressal Commission U.P. Lucknow. Complaint Case No.1 of 2017 Dr. Surendra Mohan Tripathi, adult, S/o LateGomti Prasad Tripathi, R/o House no.165, Civil Lines, Bahraich City, Post and District, Bahraich (U.P.) ...Complainant. Versus 1- Sir Ganga Ram Kolmet Hospial, 7-B, Pusa Road, New Delhi-110005 through its Director/Chairmen. 2- Dr. Nitin Gupta s/o not known, working in Sir Ganga Ram Kolmet Hospial, 7-B, Pusa Road, New Delhi-110005 3- Dr. Arvind, MBBS, MD, s/o not known, R/o Civil Lines in fornt of Maa Bhagwti Petrol Pump, Bahraich City, Post and District, Bahraich-271801 (U.P.) 4- The National Insurance Co. Ltd., 617A-620, Somdutt Chamber-II, Bhikaji Cama Place, New Delhi.-110066 ...Opp. parties. Present:- 1- Hon'ble Sri Rajendra Singh, Presiding Member. 2- Hon'ble Sri Vikas Saxena, Member. Sri O.P. Srivastava, Advocate for complainant. Sri Subhash Kumar, Advocate for the OPs no.1 & 2. Sri P.N. Bhargawa, Advocate for the OP no.3. Sri A.K. Singh, Advocate for the OP no.4. Date: 30.1.2024 JUDGMENT
Per Sri Rajendra Singh, Member- This complaint has been filed by the complainants against the opposite parties.
The brief facts of this complaint case are that, that the complainant is a retired lecturer of a degree college and his wife Mrs. Uma Tripathi was a retired principal of an inter-college. The wife of the complainant Mrs. Uma Tripathi was not feeling well due to some ailment in December 2015, so she was got medically treated by some doctors who on diagnosis found that the platelets of Mrs. Uma Tripathi had decreased and were continuously decreasing. On this, the complainant got Smt. Uma Tripathi admitted in SGPGI, Lucknow and during the course of treatment some improvement in the health of his wife appeared but that was very slow. So the complainant was not satisfied with the outcome of the treatment of SGPGI and on 30.07.2016, he brought her wife to the hospital of opposite party no.1 and she was admitted there on the same day under the care and treatment of Dr Nitin Gupta of opposite party no.1. Mrs. Uma Tripathi was 65 years of age at the time and she was allotted MR no 16930 IPD no.13099, Roon no.15, first floor and on investigation she was found suffering from ITP (Immune Thrombocytopenic Perpura), Diabetes Mellitus and Hypertension.
During the course of treatment of Dr. Nitin Gupta OP no.2, his wife was given IVIG injection, dapsone and other medicines and she felt some improvement in her health as platelets increased. So on the advice of opposite party no.2 his wife was to be discharged from the hospital of OP no.1 on 01.08.2016 but the complainant requested to retain his wife for some more time in the hospital for her betterment in the health but against the wishes of the complainant, his wife was discharged on 02.08.2016 and in the discharge summary some medicines were prescribed by OP no.2. The medical services provided by OP no.1 & OP no.2 also caused grave side effects to his wife, looking to which at least one months of medical care was required to his wife which was not allowed by OP no.1 and OP no.2. After discharge of his wife from the hospital OP no.1 to his home at the Bahraich where the condition of his wife remained somewhat normal but on 06.08.2016, she again started feeling uneasiness and depression, congestion et cetera. The complainants son informed this position of Mrs. Uma Tripathi to Dr. Nitin Gupta on phone and asked his opinion whether the medicines prescribed by him should be stopped or to be continued. He also asked if the problems which cropped up was not the side effects of the medicines prescribed by him. But the OP no.2 did not take the matter seriously and advised to contact some local doctor as it might be some seasonal problem and continue to give the medicines as prescribed by him.
On the above advice, the complainant contacted local physician Dr. Arvind, OP no.3 who examined Mrs. Uma Tripathi on 12.08.2016 and provided some medicines. But even on that medical treatment Mrs. Uma Tripathi did not feel any comfort and problem persisted. Then OP no.3 told the complainant that the problem persisting might be the side effects of medicines provided by OP no.1 and OP no.2 and the complainant again contacted OP no.2 on phone informing him the entire situation and sought advice in the medicines being given to Mrs. Uma Tripathi prescribed by him should be continued or stopped. The OP no.2 advised complainant to continue and the problems increased day by day. Looking to the deteriorating conditions of Mrs. Uma Tripathi, the complainant took her to Lucknow by ambulance but while on-board Lucknow on 13.08.2016 Mrs Uma Tripathi breathed her last. After the death of Mrs Uma Tripathi, the complainant came to know from medical experts that the complainant's wife died due to side effects of the medicines prescribed by opposite parties as the same did not suit her. The injections and medicines provided by OP no.2 and if those medicines are taken regularly, the same might prove fatal to the patient even within six weeks. The medical care provided by the opposite parties proved fatal to the complainant's wife. The medical experts opinion about dapsone side effects and Gamma IV injection were obained from Internet. This was a gross negligence and deficiency in service of the opposite parties who advised to continue the medicines prescribed by OP no.2. The opposite parties did not hear the complainant complaint regarding deteriorating condition of his wife. The opposite parties did not render proper care and cure of his wife and hastily discharged from the hospital within a week in spite of our humble request to retain his wife at least for one month. The OP no.3 also did not pay proper attention and prescribed the medicines to his wife without considering and caring about the side effects of the medicines and did not stop the medicines prescribed by OP no.2.
The complainant's wife died due to negligence and deficiency in service of the opposite parties. At the age of 65 years while the average age of her parents and their other family members has remained of 90 years. The elder brother of his wife and her father's sister are still alive and if his wife might have been cured properly, she must have remained alive even for 25 years more. Due to said and sudden death of his wife, the complainant and his family members suffered great shock and agony and lost the family environmental pleasure. The complainant wife was getting a monthly pension of ₹ 42,000/- and 90% share thereof was spent by her on her family. If she would have survived her full life of 90 years, her remaining income from the pension could be assessed Rs.1 crore 26 lakhs and the share of money spent on the complainant and other members of his family would be Rs.1,13,40,000/-. The loss and pain suffered by the complainant cannot be compensated in terms of money but the complainant is entitled for ₹ 50 lakhs as compensation and ₹ 1 lakh as expenses on medical treatment of complainant's wife. The complaint is also entitled for ₹ 25,000 towards cost of the case.
The complainant gave a legal notice to the opposite party no.1 and opposite party no.2 through Counsel dated 26.09.2016 by registered post making the above claim but they did not respond to the notice. The complaint is a consumer and the opposite parties have committed grave negligence and gross deficiency in service by not treating the complainant's wife properly. Therefore the complainant seeks the following reliefs from the opposite parties:-
(a) The opposite parties may be directed to make payment of ₹ 50 lakhs to the complainant as compensation for mental agony and financial loss of complainant; and ₹ 1 lakh as expenses of medical treatment incurred on the complainant's wife and ₹ 25,000/- towards cost of the case with interest at a rate of 18% per annum from the date of filing of this complaint till the date of actual payment.
(b) Any other relief which this Hon'ble commission may deem fit and justified, be also awarded to the complainant against the opposite parties.
The opposite parties no.1 and 2 have submitted their written statement in which they have stated that the present complaint is devoid of cause of action as the complainant had neither suffered any loss nor has been able to point out any deficiency in service of the answering opposite parties. The opposite party no.1 is a reputed hospital situated at New Delhi and opposite party no.2 is working as consultant of clinical haematology and bone marrow/stem cell transplantation at this hospital. The complainant has not come to this Hon'ble Commission with clean hands. The contents of the complaint are wrong, frivolous, vexatious and baseless. No cause of action arose in favour of the complainant and against the opposite parties. The present complaint is nothing but fancy litigation which has been filed by the complainant to harass and extract money from the answering opposite parties.
The opposite party no.1 hospital situated at New Delhi and opposite party no.2 is the consultant who is working in opposite party no.1 hospital in New Delhi. This Hon'ble Commission has no territorial jurisdiction and therefore the complainant is liable to dismissed. Mrs. Uma Tripathi, a 65 years old woman and a known patient of chronic immune thrombocytopenic perpura (ITP) was diagnosed and treated in SGPGI in December 2015 with steroids. After tapering the steroid therapy thrombocytopenia relapsed and was treated with steroid but did not benefit. It is submitted that the opposite party no.2 first saw the patient in OPD on 28.07.2016. It is further submitted that a platelet count in the hospital revealed severe thrombocytopenia. Her co morbidities included Diabetes type 2 and hypertension. In view of the severe thrombocytopenia with platelet count of 5000/ul (normal range 150 x 1000/ul) bleeding patches on the skin (Perpura) and blood blisters in the mouth. She was admitted in opposite party no.1 hospital on 30.07.2016 . The patient was treated with pulse methylprednisolone and intravenous immunoglobulin G (IVIG) therapy on 30.07.2016. It is further submitted that dapsone was started once her G6PD screening test results came out to be normal. She showed a good response to above with the platelet count rising to 32 X 1000 /ul on 31.07.2016 and bleeding symptoms subsided. It is further submitted that patient was kept under observation for the next two days and a sustained increase in platelet count was seen. Moreover as the patient was feeling well haemodynamically stable and was not requiring any intravenous medications . She was discharged from hospital on 02.08.2016. It is wrong to say that the patient was hastily discharged against the will of patient and attendants and the patient should have been kept in hospital for one month.
Not only the patient but also her son Dr. Neeraj, who himself a qualified medical physician was happy and completely satisfied with the treatment rendered by the opposite party no.1 and 2. It is further submitted that discharge medications and follow-up plan was well discussed with them. It is further submitted that patient was advised to follow-up with opposite party no.2 in OPD with complete blood count (CBC) and liver function tests (LFT) reports on 05.08.2016 but the patient did not turn up for the reasons best known to them. It is submitted that patient son informed opposite party no.2 on phone that she is doing well and the laboratory results including counts are normal. After discharge and on reaching her hometown, the patient developed congestion and uneasiness. It is further submitted that son of the patient Dr. Neeraj contacted opposite party no.2 on phone and opposite party no.2 advised them to see a qualified physician as the patient was having comorbidities of diabetes and high blood pressure. It is wrong to say that opposite party no.2 did not take the symptoms seriously as opposite party no.2 did the right thing by asking them to see a local physician who could examine her and do the necessary investigations and treatment. It is denied that the opposite party no.2 advised to give the medicines to the patient as prescribed by him at the time of discharge.
When the son of the patient Dr. Neeraj informed opposite party no.2 about her fever and breathlessness, he was again advised to see a qualified physician. As per the prescribed prescription, the patient was seen by the local physician on 12.08.2016 with fever, breathlessness and palpitation and the treating doctor has advised relevant investigations and treatment, but it appears that the patient deteriorated very rapidly and expired while being transported to a higher medical Centre on 13.08.2016. Dapsone, is an immunomodulatory drug which has been in practice for many decades. It is used extensively by dermatologists, infection disease specialists as well as haematologists. It is an oral medicine given on outpatient basis. G6PD testing is recommended to be done before the starting dapsone therapy which was normal in patient. Nowhere patient is kept hospitalisation for the sake of dapsone therapy only. The side effects include haemolytic anaemia (especially in G6 PD deficient patients), methemoglobinemia, rashes and liver function abnormalities et cetera. The patient was correctly advised to follow-up with CBC and liver function testing to observe above side effects but it appears that it was not performed by the attendants. Dapsone is a standard recommended treatment of chronic ITP and is used extensively in India as it is quite effective, safe and in expensive. Hundreds of adult IPT patients treated with dapsone. It is submitted that dapsone hypersensitivity syndrome (DHS) has not been reported. It is further submitted that attendants have also incriminated side effects of intravenous immunoglobulin G (IVIG) including fever, tightness interest and irregular heartbeat or pulse which will lead to patient's death is gross misstatement. The patient had severally low platelet count along with bleeding symptoms with skin patches and blood blisters in mouth which necessitated rapid rise in platelet count so that life had risk of brain haemorrhage could be avoided hence IVIG therapy was given. Above-mentioned adverse reaction to IVIG are mostly infusional which means they happen during the period of IVIG and Administration. IVIG was given in opposite party -1 hospital on 30.07.2016 with due precautions and under close observation and no adverse effect of IVIG was seen. Moreover, in next 72 hours till the time of discharge from hospital, no such adverse effects were seen.
As far as for the alleged dapsone hypersensitivity syndrome and that of the patient, the opposite party-2 submit as under :
DHS is a severe, multiorgan reaction to dapsone that include fever, rash jaundice, lymphadenopathy, splenomegaly and pedal oedema, skin rashes, fever and liver involvement is seen in almost 100% of patients. As per local physician's prescription on clinical examination of patient, there were no skin rashes, jaundice, anaemia, cyanosis (blue nails or tongue), hepatomegaly and lymphadenopathy which effectively rules out the side effects of dapsone. DHS is a slowly progressive in nature and most patients recover with stopping the medicine and treatment with corticosteroids. It is wrong to state that the patient should be kept in hospital for six weeks on dapsone therapy. It is submitted that as highlighted, it is an idiosyncratic drug reaction. Idiosyncratic reactions are rare, not those related and cannot be predicted.
It is difficult to speculate about the cause of unfortunate death of the patient within a few days of going back to her native place as the opposite party-2 was not directly involved . The patient wasn't good health at the time of discharge from the hospital. The opposite party-2 has rightly directed them over phone to meet the physician when the attendants are informed OP- 2 about development of fever.
It appears that the patient developed acute febrile illness, ssevere hypertension, palpitation and dyspnoea which progressed to rapidly leading her death. The clinical course of the deceased with very rapid clinical deterioration on 12.08.2016 and death within few hours even before reaching to higher medical Centre favours a cardiovascular event (myocardial infection) or cerebrovascular accident (brain stroke ). The complainant has not filed any document in relation to cause of death of the patient.
It is denied that the patient died due to the negligence and deficiency in service of the opposite parties. The patient was discharged from the opposite party no.1 hospital in a good medical condition. Utmost care was taken during the patient's treatment in the hospital and standard treatment protocols were followed. Asking for compensation on the misunderstood and unproven suspicion on idiosyncratic reaction to drug by reading on Internet is completely wrong while ignoring other more common serious medical problems are like myocardial and infection and/in an elderly woman with diabetes and high blood pressure which might have led to patient's death. Therefore it is most respectfully prayed that the Hon'ble commission may kindly dismiss the complaint filed by the complainant against the opposite parties no.1 & 2.
Opposite party no.3 has submitted his written statement in which he has stated that the complainant contacted the answering opposite party on 12.08.2016 and the answering opposite party examined the patient Mrs Uma Tripathi for her seasonal ailment and prescribed her some medicines as mentioned in the prescription. But the answering opposite party did not take any money, fee or other consideration for providing medical advice to Mrs Uma Tripathi from the complainant. The answering opposite party being a friend of complainant rendered his medical service to the complainant's wife. As such the complainant is not the consumer in this case as envisaged by Consumer Protection Act 1986. The answering opposite party acted in good faith with due diligence and without any negligence as well as the best of his ability in medically treating the patient in issue and had no malice or ill will to cause any harm to the patient nor there was any deficiency in service nor any such allegation has been made by the complainant in the complaint against the answering opposite party.
The complainant has not made any specific allegation of negligence, deficiency in service, ill will or malice to cause any harm to Mrs. Uma Tripathi, in his complaint against the answering opposite party. The answering opposite party has wrongly and intentionally been made party to the complaint without any reasonable ground or basis because the main and actual medical treatment has been provided in the instant matter by opposite parties no.1 & 2 and entire process has been against them including issuance of legal notice et cetera. As such the complaint is frivolous and vexatious against the answering opposite party. The complainant is liable to pay the costs of the answering opposite party and also to pay special damages the tune of ₹ 10,000/- U/S 26 of the Consumer Protection Act for the mental pain and agony suffered by him due to the instant case as the answering opposite party has been wrongly dragged in this case without any specific allegation of any negligence. In view of the above facts and the complainant is liable to be dismissed with costs and special damages to the tune of ₹ 10,000 as narrated above to the answering opposite party no.3.
We have heard the learned counsel for the complainant Sri O.P. Srivastava, learned counsel for the opposite parties no.1 & 2 Mr. Subhash Kumar, learned counsel for the opposite party no.3 Mr. P.N. Bhargawa and learned counsel for the opposite party no.4 Sri A.K. Singh. We have perused the pleadings, evidences and documents on record.
We have seen the discharge summary of Sir Gangaram Kolmet Hospital in which the presenting symptoms has been described as follows-
"History of Presenting Illness-
65 years old female patient was apparently all night till December, 2015 when she presented with multiple ecchymosis on hands and oral blood blister. On evaluation patient was found to have low platelet counts (2000), BMA and biopsy (22.02.2015) was done at SGPGI was suggestive of megakaryocytic thrombocytopenia within normal erythroid and myeloid precursors. She was put on oral Omnacortil 45 MG on 26/12/2016. Her platelet counsel increased momentarily but again started decreasing. Now she presented to SGR Kolmet hospital with complaints of recurrent ecchymosis hands and oral blood blister (2x2 cm). Now admitted for further management."
At the time of discharge she was asked to take some medicines including tablet dapsone 100 mg OD. She was also asked to come on 05.08.2016 with CBC and LFT reports. She was discharged on 02.08.2016 meaning thereby she was asked to follow-up only after three days. It is clear from the complaint that she did not visit on 05.08.2016 for follow-up action. So this is carelessness of the patient Mrs. Uma Tripathi. It has been vehemently argued that she was discharged in hurry though the complainant requested for further detaining in the hospital. It is on the doctor as to his patient is liable to be released or the patient is liable to be detained for further treatment in the hospital. It has been argued by the complainants counsel that tablet dapsone should have not been given for such a long period as it has adverse effects.
Dapsone is an anti-infective medicine that fights bacteria.
Dapsone is used to treat dermatitis herpetiformis (a skin condition) and leprosy.
Dapsone may also be used for purposes not listed in this medication guide.
Dapsone side effects Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficult breathing; swelling of your face, lips, tongue, or throat.
Dapsone may cause serious side effects. Call your doctor at once if you have:
worsening or no improvement in your symptoms;
jaundice (yellowing of the skin or eyes);
numbness or tingling in your hands or feet;
unusual thoughts or behavior;
new or worsening cough, fever, trouble breathing;
swelling, rapid weight gain, little or no urinating;
signs of abnormal blood cell counts-sudden weakness or ill feeling, fever, chills, sore throat, mouth sores, red or swollen gums, trouble swallowing, pale skin, easy bruising, purple or red pinpoint spots under your skin;
pancreas problems-severe pain in your upper stomach spreading to your back, nausea and vomiting, fast heart rate;
an autoimmune disorder-joint pain or swelling with fever, headaches, confusion, chest pain, shortness of breath, and butterfly-shaped skin rash on your cheeks and nose that worsens in sunlight; or severe skin reaction-fever, sore throat, swelling in your face or tongue, burning in your eyes, skin pain, followed by a red or purple skin rash that spreads (especially in the face or upper body) and causes blistering and peeling.
Common side effects of dapsone may include:
stomach pain, nausea, vomiting;
headache;
dizziness or spinning sensation;
blurred vision, ringing in your ears; or sleep problems (insomnia).
This is not a complete list of side effects and others may occur.
Now we have seen what ecchymosis is. In this regard the following article is worth reading.
Have you found a purple mark somewhere on your body? It could be ecchymosis. That's the medical term for a type of bruise.
This dark purple spot forms on your skin when blood leaks out of your blood vessels into the top layer of your skin. It's usually from an injury, and it's 1/2 inch long or bigger.
A bruise or two on your arms or legs is usually nothing to worry about. Bruises on your belly, back, or face with no obvious cause, or many new bruises, are reasons to see your doctor.
Causes If you've ever bumped your arm or leg with enough force on a hard surface, you know how bruises form. The hit or fall breaks blood vessels just under your skin's surface. If the injury causes a cut in your skin, you bleed. When there is no cut, the blood can't get out, so it pools underneath your skin.
Blood cells called platelets rush to the injury. They combine with proteins called clotting factors to form a clot. The clot plugs the broken blood vessel and stops it from bleeding.
A single bruise on your skin is often a symptom of a minor injury. Up to half of Americans bruise easily, sometimes without any obvious cause.
Women tend to bruise more than men do. So do older adults. As you age, your skin thins and loses its fatty protective layer, as well as collagen and elastin supporting the blood vessels, which leads to more bruises.
Problems with platelets, blood clotting factors, or blood vessels can cause ecchymosis, too. Easy bruising could also be a sign of a bleeding disorder such as hemophilia or Von Willebrand disease.
You may notice more bruises than usual if you take medicines that thin your blood or affect its ability to clot, such as:
NSAIDs like aspirin, ibuprofen, or naproxen Blood thinners like apixaban (Eliquis), clopidogrel (Plavix), heparin, and warfarin (Coumadin) Antibiotics Certain antidepressants Supplements such as ginkgo, ginseng, fish oil, garlic, and vitamin E Steroids If you take one of these drugs and you've noticed bruises, check with your doctor. But don't stop taking any medicine before you talk to them.
These are a few other causes of bruises:
Liver or kidney disease Problems with your bone marrow, which makes new blood cells Not getting enough vitamins such as B12, C, or K Connective tissue disease such as Ehlers-Danlos syndrome or lupus Alcohol misuse Cancer HIV and other infections Symptoms Ecchymosis turns the skin a dark purple color. As the bruise heals, it may turn green, yellow, or brown.
The bruise symptoms you're probably familiar with include:
Pain over the bruise Tenderness when you press on it Swelling Signs that your bruises could be from a bleeding disorder, rather than an injury, are:
Trouble stopping the bleeding when you cut yourself Frequent nosebleeds Heavy or very long periods Red or purple spots on your skin Diagnosis Your doctor will examine your skin and the bruises. Expect to answer questions about:
Your overall health What medicines you take Whether anyone in your family has a bleeding or clotting disorder What you were doing when the bruises appeared A blood test can help your doctor find the cause of ecchymosis. Tests can find abnormal blood cells or too few of the platelets that normally help your blood clot. You may need to have other tests if your doctor suspects that liver disease, cancer, or another condition caused your bruises.
Treatment If a minor injury like a bump caused your ecchymosis, the mark should clear up within a week or two. Hold ice to the bruise a few times a day for the first day or two.
If your bruising is due to age, your doctor may suggest that you avoid medicines like NSAIDs that could make you bleed more easily.
Which treatment you might need depends on the cause of your bruises. Your doctor has medicines for liver and kidney disease, HIV, and cancer. If a drug caused ecchymosis, you may need to stop taking it or change medicines. Taking supplements can correct a vitamin deficiency.
If you bleed a lot, you may need to get fluids through a vein or a blood transfusion. Platelet transfusions treat a low platelet count.
When to See Your Doctor A bruise that pops up from time to time or after you've injured yourself is no reason to worry. But see a doctor if you have:
Several bruises with no obvious cause A bruise that doesn't go away in a week or two A possible injury like a broken bone that caused the bruise Bleeding that doesn't stop after a few minutes Signs of too much blood loss, such as weakness, dizziness, nausea, or extreme thirst Acquired amegakaryocytic thrombocytopenia (AAMT) is a rare hematological disorder characterized by prolonged, severe thrombocytopenia, and reduced megakaryocytes on otherwise normal bone marrow biopsy. We report three cases of which two ultimately responded to treatment with eltrombopag, and one who one succumbed to illness despite treatment with multiple agents. These cases emphasize the difficulty of diagnosis and treatment of this rare condition.
1. Introduction Acquired amegakaryocytic thrombocytopenia (AAMT) is a rare hematologic disorder characterized by prolonged, severe thrombocytopenia and reduced megakaryocytes on an otherwise normal bone marrow biopsy [1]. Typically, patients present with abnormal bleeding, thrombocytopenia, and failed treatment for presumptive idiopathic thrombocytopenic purpura (ITP)0.1 The causative mechanisms are not wholly understood but have been attributed to environmental exposures (toxins, viruses, drugs), low cytokine levels, and dysregulated humoral immunity [2], [3], [4]. In most cases, etiology is undetermined. Currently, there are no standard treatment guidelines; most regimens contain immunosuppressive agents. The three cases we present demonstrate difficulty in diagnosis, treatment, and variability in the disease course. We also include a discussion of literature regarding pathogenesis and treatment.
2. Case descriptions A 50-year-old Caucasian male with PMH of diffuse large B-cell lymphoma (DLBCL) in remission and CAD, was admitted for chest pain and found to have severe thrombocytopenia. No bleeding, ecchymoses, skin rashes, lymphadenopathy or organomegaly seen. Laboratory results included a platelet count of < 5 × 103/μL, hemoglobin of 12.1 g/dL, MCV 99 fL, MCH 33.1 pg, and WBC count of 4.4 × 103/μL with 56% neutrophils, 35% lymphocytes, 8% monocytes, and 1% eosinophils. All other labs (including full infectious workup) were non-contributory. Blood smear showed severe thrombocytopenia. The patient was suspected to have ITP. However, he had refractory response to intravenous immunoglobulin (IVIG), steroids, and platelet transfusions. Due to refractory response and history of DLCBL, bone marrow biopsy was performed (Fig. 1) revealing hypocellular bone marrow (30-40%) with trilineage hematopoiesis and decreased megakaryocytes with no significant dyspoiesis, no increase in blasts, and no evidence of lymphoma; cytogenetics and next generation sequencing showed no abnormalities. Given hypocellular marrow and decreased megakaryocytes, results were inconsistent with ITP and more in favor of AAMT. Based on these findings, patient received eltrombopag 50 mg/day which was titrated to 75 mg daily at time of discharge. Ultimately, he was appropriate for discharge once platelet level stabilized at 35 × 103/μL. He was followed outpatient with continued titration of eltrombopag therapy to maintain a platelet count above 50 × 103/μL and below 200 × 103/μL. Platelets normalized and he remains disease free.
Fig. 1. Bone marrow core biopsy hematoxylin and eosin stain at 20X magnification with overall normocellular appearance.
The second case is a 51-year-old Caucasian female referred to our center after presenting to her primary care doctor with severe thrombocytopenia and petechial rash. Laboratory results included platelet count of 5 × 103/μL, hemoglobin of 10.2 g/dL, MCV 90 fL, and WBC count of 8.35 × 103/μL with normal differentials. All other labs were non-contributory. Blood smear showed marked thrombocytopenia, mild normocytic anemia with non-specific red cell anisocytosis, and adequate leukocytes with neutrophilia. She was initially suspected to have ITP and treated without response to steroids, IVIG, and platelet transfusions. Bone marrow biopsy revealed normocellular bone marrow with markedly decreased megakaryocytes, and morphologically unremarkable myeloid and erythroid precursors, and no increase in blast cells (Fig. 2); cytogenetics and NGS showed no abnormalities. Bone marrow findings were concerning for AAMT. She started eltrombopag titrated to 100 mg. Unfortunately, she remained severely thrombocytopenic, and cyclosporine was added to maintain a trough of 200-400 ng/mL. Patient was admitted for weeks, until she achieved a stable platelet count of 16 × 103/μL to allow discharge. During outpatient follow-up, platelet count improved within a few months. Cyclosporine was discontinued due to gastrointestinal toxicity. Afterwards, eltrombopag dose was tapered to 50 mg daily to maintain platelet count > 50 × 103/μL and < 200 × 103/μL. Platelets normalized and she remains disease free.
Fig. 2. Bone marrow core biopsy hematoxylin and eosin stain at 20X magnification with overall normocellular appearance.
The third case is a 68-year-old Caucasian female referred with presumed chronic ITP diagnosed several months prior with no response to steroids, IVIG, rituximab, splenectomy, eltrombopag, and romiplostim. No abnormal physical exam findings seen. Laboratory results included platelet count < 5 × 103/μL, hemoglobin 11.9 g/dL and WBC count 8.44 × 103/μL with normal differential. Blood smear showed severe thrombocytopenia with moderate normocytic anemia with polychromasia and anisocytosis. Bone marrow biopsy revealed virtually absent megakaryocytes, occasional maturing myeloid and erythroid precursor, and no morphologic or immunophenotypic evidence of increase in blasts or lymphoma (Fig. 3); cytogenetics and NGS showed no abnormalities. Bone marrow findings were concerning for AAMT and azathioprine 50 mg was added to her outpatient regimen of romiplostim. This was later modified to the sole use of azathioprine 75 mg which continued for a month until stopped due to refractory response (platelet count < 5 × 103/μL). She then completed weekly bortezomib injections with no response. At this time, she fell with subdural hematoma evident on CT requiring a six month hospital course. She was started on equine ATG and cyclosporine for two months with no response. In addition, she was deemed unsuitable for bone marrow transplantation due to frailty and no social support. She was discharged home with hospice and passed away.
Fig. 3. Bone marrow core biopsy hematoxylin and eosin stain at 20X magnification with overall normocellular appearance.
3. Discussion AAMT is a diagnosis of exclusion and a rare condition of unknown incidence most seen in the later years of life [5], [6], [7]. Some key pertinent findings seen in AAMT include peripheral blood thrombocytopenia, absence of splenomegaly, a lack of response to IVIG and corticosteroid treatment, transient response to platelet transfusions, and virtual absence of megakaryocytes on bone marrow biopsy with otherwise intact cell lines and often with a lack of cytogenetic abnormalities [2]. It is often mistaken for ITP or conditions that cause thrombocytopenia, and thus the actual incidence is likely underestimated [5], [7], [8], [9]. The differential diagnosis of thrombocytopenia is extensive and causes include drug-induced thrombocytopenia, bone marrow failure disorders, hematologic malignancies, infections, autoimmune diseases, nutritional deficiencies, thrombotic microangiopathies and ITP [1], [2], [10].
Clinical presentation and morphologic findings on bone marrow biopsy can aid in reaching an accurate diagnosis. For example, ITP an autoimmune disorder is usually seen in immunocompetent children and young adults following a viral infection and bone marrow reveals increased megakaryocyte synthesis [11]. Whereas aplastic anemia involves immune-mediated destruction which can be asymptomatic early in disease course or present with fevers and infection, pancytopenia is seen on routine lab testing and bone marrow reveals failure in production of all cell lines [12]. Myelodysplastic syndromes usually occur in the elderly with non-specific clinical findings mainly from anemia. Obtaining bone marrow biopsy is essential to diagnosis and is often hypercellular with dysplasia in at least one cell line [13], [14].
Currently, pathogenesis of AAMT remains unclear. AAMT may not be a sole clinical entity, and instead reflective of heterogeneous disorders with the same clinical endpoint [15]. Proposed mechanisms characterized in literature include: acquired stem cell defect, exogenous agents inhibiting megakaryopoiesis, and immune mediated inhibition of megakaryopoiesis [1]. Multiple reports describe AAMT with progression to aplastic anemia and summarized by Hussein et al. In addition, clonal bone marrow disorders such as myelodysplastic syndromes have been described to mimic AAMT [16], [17]. This suggests that AAMT could result from an acquired stem cell defect and be part of the same continuum as aplastic anemia and myelodysplastic syndromes.
Exogenous agents inhibiting megakaryopoiesis can include occupational chemical exposure, medications, or viral infections [4], [18], [20]. Reports of AAMT in the setting of immune checkpoint inhibitor therapy have been published by Suyama et al. and Park et al. [18], [19]. Implicated viral infections include parvovirus-B19 and Hepatitis C [20], [21].
Immune-mediated inhibition of megakaryopoiesis via humoral and cellular mechanism have been described. One humoral mechanism involves autoantibodies to thrombopoietin receptor (c- MPL) [18], [21]. Other mechanisms include anti-thrombopoietin (TPO) receptor antibodies, cytotoxic antibodies against megakaryocyte colony forming unit (CFU-Meg), suppressor T-cells directed against CFU-Meg, and intrinsic defects in CFU-Meg [8], [22], [23], [24], [25].
Presently, there are no established treatment guidelines for AAMT. Case reports have demonstrated various response to cyclosporine, eltrombopag, romiplostim, rituximab, anti- thymocyte immunoglobulin, allogeneic bone marrow transplant, and others. In contrast with ITP, immunosuppression with corticosteroids and IVIG are oftentimes insufficient [6], [7], [20], [23]. There is likely a positive publication bias in the reporting of treatment modalities that resulted in complete remission, which makes it difficult to determine success rate. Furthermore, prognosis is unclear in the setting of high clinical variability, limited understanding of pathogenesis, and a small sample of reported cases.
In conclusion, further research must be done to delineate the most appropriate treatment approaches for patients based on their respective pathophysiology. Our case series reflect the challenge of diagnosing AAMT, and variable outcomes of this disease. With our case series, we strive to add to the literature more examples of this rare disease that has no established treatment guidelines.
Patient consent statement Informed consent was obtained from all three patients involved in this case series. They were provided information and had had the opportunity to ask questions. The patients consented to publication of information about them in a journal or thesis.
References 1-G.E. Brown, H.M. Babiker, C.L. Cantu, A.M. Yeager, R. Krishnadasan "Almost Bleeding to Death": The Conundrum of Acquired Amegakaryocytic Thrombocytopenia Case Rep. Hematol., 2014 (2014), pp. 1-5 2- N. Agarwal, J.E. Spahr, T.L. Werner, D.L. Newton, G.M. Rodgers Acquired amegakaryocytic thrombocytopenic purpura Am. J. Hematol., 81 (2) (2006), pp. 132-135 M. Colovic, S. Pavlovic, N. Kraguljac, N. Colovic, G. Jankovic, D. Sefer, N. Tosic Acquired amegakaryocytic thrombocytopenia associated with proliferation of gamma/delta TCR T-lymphocytes and a BCR-ABL (p210) fusion transcript Eur. J. Haematol., 73 (5) (2004), pp. 372-375 3- M. Patel, A. Kalra, R. Surapaneni, R. Schwarting, L. Devereux Acquired amegakaryocytic thrombocytopenia in a patient with occupational chemical exposure Am. J .Ther., 21 (1) (2014), pp. e17-e20 4- S.A. Hussain, H. Fatima, H. Faisal, M. Bansal Acquired Amegakaryocytic Thrombocytopenia Progressing to Aplastic Anaemia Eur. J. Case Rep. Intern. Med., 9 (9) (2022), Article 003479 J.P. Novotný, B. Köhler, R. Max, G. Egeret Acquired Amegakaryocytic Thrombocytopenic Purpura Progressing into Aplastic Anemia Prague Med. Rep., 118 (4) (2017), pp. 147-155 5- A. Roeser, G. Moulis, M. Ebbo, L. Terriou, E. Poullot, B. Lioger, M. Chilles, H. Labussière-Wallet, C. Mausservey, M. Pha, M. Puyade, S. Cheze, N. Limal, M. Michel, B. Godeau, M. Mahévas Characteristics, management and outcome of acquired amegakaryocytic thrombocytopenia Br. J. Haematol., 198 (3) (2022), pp. 595-599 6- N. Ikeda, Y. Hisano, T. Kamao, M. Uno, T. Mizushima Acquired Amegakaryocytic Thrombocytopenia Associated With Autoimmune Hemolytic Anemia Cureus, 14 (7) (2022), p. e27315 7- A.M. Roy, M. Konda, G.K. Sidarous, D. Atwal, S.A. Schichman, A. Kunthur Acquired Amegakaryocytic Thrombocytopenia Misdiagnosed as Immune Thrombocytopenia: A Case Report Perm. J., 24 (2020), pp. 1-3 8- D. Geissler, J. Thaler, G. Konwalinka, C. Peschel Progressive preleukemia presenting amegakaryocytic thrombocytopenic purpura: association of the 5q- syndrome with a decreased megakaryocytic colony formation and a defective production of Meg-CSF Leuk. Res., 11 (8) (1987), pp. 731-737 A. Vaillant, N. Gupta ITP-Immune Thrombocytopenic Purpura StatPearls, Treasure Island (FL) (2023) 9- A. DeZern, J. Churpek Approach to the diagnosis of aplastic anemia Blood Adv., 5 (12) (2021), pp. 2660-2671 L. Adès, R. Itzykson, P. Fenaux Myelodysplastic syndromes Lancet, 383 (9936) (2014), pp. 2239-2252 J. Dotson, Y. Lebowicz Myelodysplastic Syndrome StatPearls, Treasure Island (FL) (2023) Tirthani E, Said MS, De Jesus O. Amegakaryocytic Thrombocytopenia. StatPearls. Treasure Island (FL).
Y. Xue, R.i. Zhang, Y.u. Guo, J. Gu, B. Lin Acquired amegakaryocytic thrombocytopenic purpura with a Philadelphia chromosome Cancer Genet. Cytogenet., 69 (1) (1993), pp. 51-56 Al Pakra M, Al Jabri A, Hanafy E. Myelodysplastic Syndrome Presenting as Amegakaryocytic Thrombocytopenia in a Collodion Baby. J Investig Med High Impact Case Rep, 2015. 3(3): p. 2324709615605637.
T. Suyama, M. Hagihara, N. Kubota, Y. Osamura, Y. Shinka, N. Miyao Acquired amegakaryocytic thrombocytopenia after durvalumab administration J. Clin. Exp. Hematop., 61 (1) (2021), pp. 53-57 A.K. Park, J.C. Park, H. Al-Samkari Pembrolizumab-Induced Acquired Amegakaryocytic Thrombocytopenia and Successful Combination Treatment With Eltrombopag, Romiplostim and Cyclosporine: A Brief Communication J. Immunother., 45 (7) (2022), pp. 321-323 J. Bhattacharyya, R. Kumar, S. Tyagi, J. Kishore, M. Mahapatra, V.P. Choudhry Human parvovirus B19-induced acquired pure amegakaryocytic thrombocytopenia Br. J. Haematol., 128 (1) (2005), pp. 128-129 S. Ichimata, M. Kobayashi, K. Honda, S. Shibata, A. Matsumoto, H. Kanno Acquired amegakaryocytic thrombocytopenia previously diagnosed as idiopathic thrombocytopenic purpura in a patient with hepatitis C virus infection World J. Gastroenterol., 23 (35) (2017), pp. 6540-6545 R. Hoffman, E. Bruno, J. Elwell, E. Mazur, A. Gewirtz, P. Dekker, A. Denes Acquired amegakaryocytic thrombocytopenic purpura: a syndrome of diverse etiologies Blood, 60 (5) (1982), pp. 1173-1178 View in ScopusGoogle Scholar [23] M. Katai, T. Aizawa, N. Ohara, K. Hiramatsu, K. Hashizume, T. Yamada, K. Kitano, H. Saito, T. Shinoda, S. Wakata, T. Nakahata Acquired amegakaryocytic thrombocytopenic purpura with humoral inhibitory factor for megakaryocyte colony formation Intern. Med., 33 (3) (1994), pp. 147-149 F. Benedetti, D. de Sabata, G. Perona T suppressor activated lymphocytes (CD8+/DR+) inhibit megakaryocyte progenitor cell differentiation in a case of acquired amegakaryocytic thrombocytopenic purpura Stem Cells, 12 (2) (1994), pp. 205-213 A.M. Gewirtz, M.K. Sacchetti, R. Bien, W.E. Barry Cell-mediated suppression of megakaryocytopoiesis in acquired amegakaryocytic thrombocytopenic purpura Blood, 68 (3) (1986), pp. 619-626 So it is clear that the symptoms are not ordinary symptoms and utmost care should have been taken by the patient and her family members. When she was called for follow-up action, she did not appear before the appellant. It is also clear that complainant's son is Dr. Neeraj Tripathi who contacted on phone to opposite party no.2. It is not clear whether he was advised to discontinue the dapsone or not. We have seen the haematology laboratory report dtd 02.08.2016 of the appellants hospital in which the platelet count is 167 while the references 150 - 450. It means that the patient count has increased and now it came under the normal reference. So at the time of discharge the platelets were in the normal range. After returning home the patient did not visit the opposite party hospital on 5 August 2006. She was not taken to any local doctor on the said date and in spite of it she was taken to the doctor on 12.08.16 and no reason has been given for such a delay. The doctor asked the patient to undergo for some tests which has been written on the right side of the prescription. The doctor at Bahraich did not mention dapsone tablet. It is not clear that for how many days she took dapsone tablet and if it has been consumed after 05.08.2006 , why did she take it after the said date as there is no presumption regarding to continue this drug after 05.08.2006.
As we have seen that the patient did not honour the doctor's advice and also the complainant did not visit on the date she was asked to come for follow-up action. The complainant's son is also a doctor who can very well tell about the drugs et cetera. So in this case it is clear that the complainant showed utmost negligence and carelessness in the treatment of his wife. We do not find any adverse effect of the use of dapsone which was being given OD. The complainant filed the complaint agaisnt the opposite parties without any sufficient cause and without any sufficient evidence. He failed to produce any evidence regarding the carelessness or negligence of the doctors.
Before going further we have to see the oath taken by the doctors before entering into medical profession.
"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."
The human body is a complex structure. The doctors are trained to teach the different aspects of the human body regarding diagnosis and treatment. Dr is not liable for any treatment in each and every case. If the circumstances speak themselves regarding negligence and carelessness on the part of Dr than we can hold them liable for negligence and deficiency in services.
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.
DOCTRINE OF RES IPSA LOQUITAR 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 Achutrao Haribhau Khodwa 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."
Now we have to see that whether the maxim res ipsa loquitur applies in this case or not. Here the carelessness of the doctor could not be proved by the complainant. Instead the carelessness on the part of the complainant and he unnecessary made the opposite parties, opposite parties no.1 to 3. When you are not amicable to the advice of the doctor, how can you blame the doctor. So in this case the doctor did his best but it is the complainant who did not follow the advice of doctor and could not visit the doctor on 05.08.2006, instead he visited local doctor on12.08.2006. The local doctor advised for some clinical and pathological test which the complainant did not under. So in this case we are of the opinion that there is no negligence on the part of the doctor but there is negligence on the part of the complainant. The complainant is liable to pay exemplary cost to the opposite parties no.2 and 3.
So from all the circumstances and all the documents which are on record we come to the conclusion that the complainant should be imposed exemplary cost of ₹ 2 lakhs each to be paid to the opposite party no 2 and 3 for making them unnecessary party, harassing them without any cogent evidence. The complaint case is liable to be with exemplary cost of ₹ 2 lakhs each to be paid to the opposite parties no.2 and 3 by the complainant within 30 days from the date of judgment of this complaint case otherwise interest shall be payable on this amount.
ORDER The complaint case is dismissed with cost. The complainant is directed to pay exemplary cost of Rs.2 lakhs each to the opposite parties no.1 & 2 with interest at a rate of 9% from 02.01.2017 (the date of filing of the complaint case) if paid within 30 days from the date of judgment of this complaint case otherwise the rate of interest shall be 12% from 02.01.2017 till the date of its actual payment.
The stenographer is requested to upload this order on the Website of this Commission today itself.
Certified copy of this judgment be provided to the parties as per rules.
(Vikas Saxena) (Rajendra Singh) Member Presiding Member Judgment dated/typed signed by us and pronounced in the open court. Consign to the Record-room. (Vikas Saxena) (Rajendra Singh) Member Presiding Member Dated 30.1.2024 JafRi, PA I C-2 [HON'BLE MR. Rajendra Singh] PRESIDING MEMBER [HON'BLE MR. Vikas Saxena] JUDICIAL MEMBER