State Consumer Disputes Redressal Commission
Sri Sujit Kumar Nandi vs Ramkrishna Mission Seva Pratisthan @ ... on 10 June, 2014
DRAFT STATE CONSUMER DISPUTES REDRESSAL COMMISSION WEST BENGAL 11A, MIRZA GHALIB STREET KOLKATA 700 087 S.C. CASE NO.SC/09/O/2004 DATE OF FILING:19/05/04 DATE OF FINAL ORDER:10/06/14 COMPLAINANTS : 1) Sri Sujit Kumar Nandi S/o-Dr. Kanailal Nandi 2) Smt. Nupur Nandi W/o-Sujit Kumar Nandi Both are residing at 28, Pratapaditya Place P.S.Tollygunge Kolkata-700 026 OPPOSITE PARTIES : 1) Ramkrishna Mission Seva Pratisthan alias Sishumangal Hospital, 99, Sarat Bose Road P.S.Tollygunge Kolkata-700 026 Represented by its Secretary Swami Sarbolokanandaji along with the concerned employees or agents i.e., doctors & nurses of the said hospital 2) Dr. Dhiman Ganguly Senior Doctor S/o-Late Saktipada Ganguly 90A/1B, Suren Sarkar Road P.S.Beliaghata, Kolkata-700 010 3) Dr. N.S. Narayan Senior Doctor S/o-Late K. R. Narayanswamy 28/4, Gariahat Road (South) P.S. Lake, Kolkata-700 029 4) Dr. Ashis Patra, Anaesthesist Sishumangal Hospital 99, Sarat Bose Road P.S.Tollygunge Kolkata-700 026 5) Dr. Hindol Dasgupta Senior Doctor S/o-Ashim Ranjan Dasgupta 42C, Syed Amir Ali Avenue P.S. Karaya Kolkata-700 072 6) Dr. Jayanta Sinha, M.O. S/o-Jogabrata Sinha Nilachal Apartment Nabapally, Joka P.S. Joka, Kolkata-700 104 Attached with the said Hospital 7) Dr. Ananya Biswas Medical Registrar 1/5, Ibrahimpur Road Government Housing Estate P.S. Jadavpur Kolkata-700 032 Attached with the said Hospital 8) Dr. Prasun Ghosh, M.O. 81/2A, Belgachia Road P.S. Belgachia Kolkata-700 037 Attached with the said Hospital BEFORE : HONBLE JUSTICE : Mr. Kalidas Mukherjee President HONBLE MEMBER : Mrs. Mridula Roy HONBLE MEMBER : Mr. Tarapada Gangopadhyay FOR THE COMPLAINANTS : Mr. Chanchal Nag Choudhury Ld. Advocate FOR THE OPPOSITE PARTIES : Mr. Sukalyan Sarkar Ld. Advocate Mr. A. Mukhopadhyay Ld. Advocate : O R D E R :
HONBLE JUSTICE MR. KALIDAS MUKHERJEE, PRESIDENT This is a complaint case wherein the Complainants alleged that on 18th May, 2002 at about 7.30 p.m. the minor daughter Kumari Nabanita Nandi aged about 15 years, since deceased, was taken to the emergency clinic of Ramkrishna Mission Seva Pratisthan alias Sishumangal Hospital, Kolkata-700 026 as she was feeling unwell after mistakenly tasting a small pinch of granules of Baygon Insect Bait out of her childish curiosity at the residence of the Complainants. She was taken to the emergency clinic of Ramkrishna Mission Seva Pratisthan alias Sishumangal Hospital. The then on duty doctors (one was a female and the other was a male) of the emergency clinic checked up the patient and treated her with stomach wash. The doctors reported that they could not find any foreign particle in the said stomach wash. Although the minor daughter of the Complainants felt herself well and hungry, expressed her strong desire to return home, but the two doctors after holding a short discussion between themselves advised the Complainants wife and other relatives to admit the patient at the said Hospital for necessary observation for a day only to be followed by her release on the next afternoon, that is, 19/05/02. The physicians of the clinic assured the wife of the Complainant and other relatives that there was nothing to be worried about the minor daughter. Accordingly, the minor daughter was admitted to the female ward, 4th floor, block-C, ward no.C-3 in the bed no.C-118, under the senior doctor, namely, Dr. D. Ganguly, the OP No.2 herein and Dr. N. S. Narayan, the OP No.3 of the said Ramkrishna Mission Seva Pratisthan alias Sishumangal Hospital on the same night, that is, 18/05/02 at about 9.30 p.m. At about 10 p.m. on 18/05/02 without communicating any information about the minor daughter and without entertaining any request to obtain information of the said minor daughter, the OPs simply handed over a prescription of medicines and injections including Atropine injection of 8 ampoules. Accordingly, the prescribed medicines were purchased by the Complainant and handed over to the on duty nurses. But later on it was most shockingly learnt that no food or drinks was at all given to the said minor girl. At the night of 18/05/02 it was told that the minor daughter was under observation and her condition was the same and the hospital Authority handed over another prescription including Atropine injection of 20 ampoules. In the early morning of the next day, that is, 19/05/02 at about 6.30 a.m. the minor daughter of the Complainant was weeping and said that she was very hungry as no food or drinks were given to her throughout the last night. Series of injections were administered to her. The Complainants wife became totally perplexed. The on duty nurses handed over a prescription containing the advice of 50 ampoules of Atropine injection. Accordingly, the said injections were purchased and handed over to the on duty nurses. The wife of the Complainant could not find any doctor attending the said ward. The concerned treating doctors treated the minor daughter with a reckless continuous administration of excessive huge doses of Atropine injections (more than 118 ampoules), both intramuscularly and intravenously within an extremely short span of 18 hours into the body of the said minor patient who was lying in an empty stomach. In the process the body of the minor patient rapidly became poisonous and toxic due to administration of Atropine injections. The situation thus went out of control and ultimately leading to the premature death of the minor daughter of the Complainants. The dose of said Atropine injection was fatal and dangerous. No senior doctor under whom the said minor daughter remained admitted cared to attend her right from the state of admission till her premature death. The Complainants were kept completely in dark and thus depriving them of the chance to transfer their said minor daughter to a better Hospital and consult other medical experts. Under the circumstances, the complaint was filed praying for compensation of Rs.75 lakh and for costs.
OP Nos.1 to 6 contested the case. None appeared on behalf of OP Nos.7 and 8.
Complainant filed written notes of argument. OP Nos.1, 4 and 6 jointly filed written notes of argument. OP Nos.2 and 3 filed written notes of argument separately. OP No.5 also filed written notes of argument separately. It is the case of the OPs that the petition of complaint is not maintainable in facts or in law. On 18/05/02 at 7.55 p.m. the emergency officer had noted that the patient Nabanita Nandi had ingested Diazepam tablets and Baygon powder (granules). The doctor also noted that the patient was restless and there was a history of vomiting 3 times. A police case note was also made. This was followed by a note from the Medical Registrar on call that this was a case of unknown poisoning and the patient was advised admission in ward C-3 under Dr. D. Ganguly, Dr. N. S. Narayan and Dr. H. Dasgupta. There was also an outdoor registration card noted at 7.55 p.m. confirming the details of the patient along with a police case stamp and suggesting on its reverse admission as above. On 18/05/02 at 10.15 the patient complained of nausea, discomfort and dizziness following deliberate self-ingestion of Baygon granules and Diazepam tablets. As per note this happened at about 6 p.m. on that date followed by episode of disharmony in family. Treatment was given as per the advice mentioned in the treatment chart. Blood samples were taken for investigation. On 19/05/02 at 10 a.m. the visiting physician saw the case with the junior doctors and the patient was found to have a temperature, her pupils were dilated and not reacting. The treatment chart carried an instruction to omit Atropine.
After 7.45 a.m. on 19/05/02 half hourly Atropine injection was not given and Atropine by continuous infusion was stopped at 10 a.m. on that day. At 10.20 p.m. on 19/05/02 the patient had a temperature of 105 degree Fahrenheit and had tachycardia. Blood slides for malaria parasite was considered and Paracetamol injection was suggested. A consideration for transfer to I.T.U. was noted. Treatment chart shows that injection Paracetamol was given. At 12.20 a.m. the patient was noted to have severe respiratory distress with a fever of 104, respiratory rate of 60/minute and heart rate 180/minute. The condition of the patient was explained to her relatives and also the prognosis was explained. The patient was received in I.T.U. at 1.10 a.m. on 20/05/02 where she was found deeply comatosed, but not cyanosed and she was not responding to pain stimuli. Chest examination revealed bilateral coarse, crepitations. The pupils were dilated and there was no neck stiffness. She was put on ventilatory support and her oxygen saturation was found to be 100%. Chest examination revealed crepitations. At 2 a.m. on 20/05/02 she was started on dobutamine infusion for her low blood pressure. At 2.15 a.m. her cardiac monitor showed a systole. At 2.45 a.m. she had continued supra ventricular tachycardia with a systolic blood pressure of 60 mm Hg. Resuscitation attempts were unsuccessful and she was declared clinically dead at 3 a.m. on 20/05/02. The admission sheet shows that she was admitted on 18/05/02 and expired on 20/05/02 and that the final diagnosis was organophosphorus poisoning and supra ventricular tachycardia. The text book and medical reference clearly say that the patient with a history of poisoning by this group of substances can relapse and even die after initial stabilization by anti-dotes. The main cause for worry was respiratory muscle paralysis leading to death. In this type of cases the stomach of the patient has to be kept empty so that there is no occurrence of vomiting and aspiration causing respiratory problem. The injection Atropine was the specific anti-dote in this type of cases. In some cases very high dose of Atropine may be required depending on the degree of poisoning and duration of exposure to it.
From the medical record of the patient it would appear that the death of the patient occurred not due to the inability of the doctors to treat the patient, but due to the complications of the case and also due to the fact that by the time when the patient was brought to the emergency of the Hospital, the poison had already entered into the circulation being absorbed in the blood through small intestine. The patient developed complication arising out of her consumption of a lethal dose of Baygon at her residence and she did not die of Atropine over dose. Atropine was discontinued at least 16 hours before she died and its half life is about 4 hours. Correct diagnosis was made and proper treatment was provided along with periodic monitoring of the patients condition and response. Doctors have acted very reasonably and within their limits of professional competence. The visiting doctors are not employees or agents of the Hospital, but are honorary visiting physicians of the Hospital. There was no professional misconduct. The management was correct and there was no negligence in duty. Adequate medical attention was provided and treatment was provided as per standard medical practice and procedure.
The Learned Counsel for the Complainant has submitted that the patient was 15 years of age at the material time and possibly she took Baygon Spray. It is submitted that the stomach wash was made, but nothing poisonous was found and as per the advice of the doctor patient was admitted and huge number of Atropine injection were administered. It is contended that the Complainant purchased those medicines and the receipts have been filed. It is submitted that the treating doctors did not talk to the patient party and on 19/05/02 at 4.30 p.m. the patient party found the eyes of the patient closed and she was not responding after repeated calls. It is submitted that there was no disclosure under whose doctor the patient was admitted. It is submitted that there was wrong diagnosis and the Atropine injections were administered on suspicion. It is submitted that due to overdose of Atropine injection the patient expired. It is contended that the test report from the laboratory has not been filed. It is submitted that it was not clinically ascertained whether it was a case of Baygon poisoning.
The Learned Counsel for the OPs submitted that the doctors acted as consultants and they rendered free services and they were not the employees under the Hospital. It is contended that they were the visiting doctors and, as such, complaint against them was not maintainable. It is submitted that a petition was filed challenging the maintainability of the complaint case and it was directed that it would be heard at the time of the hearing of the case. It is contended that the junior doctors did their best and they have not been impleaded in this case. It is submitted that Atropine injection was rightly administered and it was the only anti-dote of Baygon granules. It is submitted that no contrary opinion of medical expert was adduced by the Complainant.
We have heard the submission made by both sides and perused the materials on record. It has been argued by the Learned Counsel for the OPs that the doctors rendered free service to the OP No.1 and they did not realize any fees from the patient and, as such, against the doctors the petition of complaint is not maintainable. It is further submitted that on call by the OP No.1 the doctors visited the Hospital as visiting physician and rendered services to the OP No.1. The Learned Counsel for the OPs has referred to the certificates being marked Annexure-A to the effect of rendering free services. Written notes of argument on behalf of OP No.3 has been filed to the effect that the OP No.1 is a charitable Institution run mainly by public donation from the beginning and only a small percentage of the total expenditure comes from the charges paid by the patients. It has also been mentioned in the certificates issued by OP No.1 that all visiting and deputy visiting doctors and a few paramedical staff served the Hospital free of charges by the inspiration of Karma Yoga instructed by Swami Vivekananda.
It is contended that between the Complainant and the OP doctors there is no consumer and service provider relationship.
The OP No.1 annexed with the W.V. the copies of treatment sheets and the receipts. It appears therefrom that on 19/05/02 the sum of Rs.500/- was realized from the Complainant. It further appears that on requisition by the Hospital medicines were purchased by the Complainant and he supplied the same to the Hospital. There is nothing on record to show that treatment was done free of cost. Under such circumstances, we are of the considered view that the Complainants are consumers within the meaning of Section 2(1)(d) of the C. P. Act, 1986.
It is the consistent case of the Complainants that the girl was admitted with the history of suspected consumption of Baygon granules and after stomach washes the condition of the patient was well, but upon advice of the doctors the patient was admitted for further observation.
It has also been contended by the Complainants that the assurance was given that the patient would be discharged on the next day.
The moot point in this case is whether the administration of Atropine injection was the cause of the death of the patient.
On this point it has been stated in the written argument of OP No.3 in Paragraph-3(a) that the history of the patient was taken on admission clearly show that there was a family disharmony due to which the patient consumed a handful of Baygon granules and unknown strength of Diazepam tablets at her home. The entries in the treatment sheet also reveals in support of such contention.
In Paragraph-3(b) of the W.N.A. of OP No.3 it has been stated that the patient was given a treatment of stomach wash which was done in a routine manner on these patients to ensure that even if the small amount of the poisonous substance is present in the stomach and has not yet gone to the intestine it can be washed out. It has been stated that in the instant case the main worry was that the poison had already entered into the blood with definite possibility of poison exerting its effect on the various tissues of the body and this had happened only due to the delay caused by the party in bringing the patient to the Hospital. In Paragraph-3(d) of the W.N.A of OP No.3 it has been stated relying on some medical texts that the patient with a history of poison by this group of substances can relapse and even die after initial stabilization by anti-dotes. It has further been stated that it was associated with severe muscle weakness and appeared to be due to the nicotinic effects of the poisonous substance and Atropine did not have any effect on this.
It was further stated that the main cause for worry herein was respiratory muscle paralysis leading to death.
The Learned Counsel for the OPs in this connection has referred to the death certificate wherein cause of death has been mentioned as organophosphorus poisoning with supraventicular tachycardia.
Dr. D. Ganguly, OP No.2 has been examined on Commission. As against question no.63 he has answered as follows:
Q. No.63: Can you say what is the standard dose of Atropine that can be administered to a 14-years old girl ?
Ans. There is no standard dose. The dose is treated monitoring the patients condition in this poisoning.
As against question no.64 he answered as follows:
Q. No.64: Dr. Ganguly, do you mean to say that there is no maximum limit to such dose of Atropine ?
Ans. Dose depends on severity of the poisoning.
As against question nos.66 and 68 he answered as follows:
Q. No.66: Dr. Ganguly, in this case 102 Ampoules of Atropine were administered to the patient in course of 12 hours. Do you treat it is a normal ?
Ans. Yes. It is not unusual in this type of poisoning.
Q. No.68:
Would you agree if it means 3 Mg. of Atropine if administered will give the desired result and 66 Mg. can be fatal for a patient with this poisoning ?
Ans. This treatment is necessary but without poisoning we never use this high dose.
OP No.3 Dr. N. S. Narayan was examined on Commission. As against question nos.22, 23, 24, 25, 27, 28, 30 and 31 he answered as follows:
Q. No.22:
From this chart can it be safely concluded that the poison had already been entered into her intestine ?
Ans. It would rather appear from this chart that poison had already entered into blood stream and this would be during and after its absorption from the intestine.
Q. No.23: Dr. Narayan is it reflected in this chart or from the hospital record available to us ?
Ans. Looking at the hospital note and record I would agree with this. From record it appears to me that at about 5.20 A.M. on 19.05,2002 the child had still features of Baygon poisoning and the poison is in the blood stream.
Q. No.24: Can you say as to how long a time it takes for such type of poisoning to affect the blood stream after intake ?
Ans. This will depend upon absorption characteristic of particular substance. Normally the stomach contents are emptied into the intestine in about 3 hours.
After that depending on the duration of presence of the substance in the intestine, the absorption can continue into the blood stream.
Q. No.25: Do you consider injection of 102 ampoules Atropine injections in 12 hours to a 14 years girl to be normal ?
Ans. As per the record noted and as per the childs general condition of health I would be inclined to agree with the management given to her at that time. She was conscious and alert and spoke to her mother at about 6-15 to 6-30 in the morning on 19.05.2002. At this time she already was given a substantial amount of atropine. She could tolerate this in my opinion because of the presence of some anti-atropine substance (In this case Baygon) in her system.
Q. No.27: Can you say with certainty from the treatment sheet she had indeed taken poison if so, how is it reflected ?
Ans. I say this because there is no entry of the laboratory examination of the stomach wash in the chart. The hospital notes have recorded consumption of baygon powder.
The hospital notes have recorded clinical parameter suggesting baygon was present in her system. The hospital note also confirmed that about 102 ampoules of atropine injections were administered to this child. The hospital note also shows that she has tolerated this amount of atropine injections. Chemical analysis report should not be waited for in the treatment of Baygon poisoning.
The treatment is purely based on clinical ground otherwise it may turn fatal if you wait for the report.
Q. No.28: Dr. Narayan since the poison was suspected at the initial stage, there were no pre-cautionary steps is taken to ensure that if the substance taken be not poison then the treatment meted to the patient will not result in a poison. What I mean to say that if the substance taken was not a poison will atropine injection be administered thereto if so how much ?
Ans. At the outset I would like to clarify that none of the treatment was meted out by me. If I am to disagree with the management I should have said so when I visited the patient in question at 10.00 AM. I was clinically convinced that she had baygon in her system otherwise she could not have tolerated the amount of atropine that was administered to her. At no stage the hospital record have shown that she had features of atropine poisoning.
At 10.00 AM on 19.05.2002 when I saw her I thought she was clinically atropinised and I advised to withhold.
Q. No.30: In this case we find that at about 12.20 A.M. On 19.05.2002 tachycardia is shown at 180 per minutes can it be deemed to be because of atropine injections ?
Ans. In this case it appears to me that since atropine was continued to be administered over night and the child was conscious in the morning at about 6.15 a.m. and spoke to her mother it would be likely from baygon poisoning.
Q. No.31: Dr. Narayan can you please go through other entries in that particular column namely mainly at 12.20 AM on 19.05.2002 of the treatment-sheet and from the other entries it is seen that certain symptoms are shown. Would you recognize the condition of atropine under this circumstances ?
Ans. Baygon poisoning is manifested and causes respiratory problem and severe respiratory distress and Tachypnoea Tachycardia and fever.
In the initial hour of baygon poisoning atropine is specific antidote and should be continued to till muscarinic effects of baygon poisoning are manifested.
In view of such evidence of the OP doctors it is clear that according to the severity of the case of poisoning the dose of Atropine is determined. It is also the specific contention of the OP doctors that in the instant case the poisoning had already affected the blood stream after intake. Under such circumstances, the Complainant could not rebut the evidence of the OP doctors by adducing any expert evidence. The Complainant wanted to adduce the expert evidence by filing Miscellaneous Application bearing no.193 of 2013 which was dismissed on 29/04/13. As per order dated 13/02/14 it was recorded that the Complainants moved the Hon'ble National Commission against the dismissal of the MA 193 of 2013 which was dismissed and thereafter the Complainants submitted that he had sent one review application by post, but ultimately no order from the Hon'ble National Commission could be produced by the Complainant and the matter was heard. Therefore, in absence of any expert evidence it cannot be said that the administration of Atropine injection was erroneous or that the patient died because of the overdose of Atropine injection. In the decision reported in 2011 (2) CPR 372 (NC) [Baljinder Singh Vs. National Insurance Co. Ltd. & Ors.] it has been held that medical negligence cannot be presumed and has to be proved by complainant. In the decision reported in III 2012 (1) 112 (NC) [ ] it has been held that medical complications cannot always lead to inference of medical negligence. Having regard to the evidence on record and upon considering the submission made by the Learned Counsel for the parties, we are of the considered view that the Complainants could not prove the alleged medical negligence on the part of the OPs. The Complainant, therefore, is not entitled to get any relief and the complaint is liable to be dismissed.
The petition of complaint is dismissed. We make no order as to costs.
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MEMBER(TG) MEMBER(L) PRESIDENT