National Consumer Disputes Redressal
Dr. K.K. Sharma vs Fortis Hospital on 17 March, 2016
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI FIRST APPEAL NO. 243 OF 2008 (Against the Order dated 15/04/2008 in Complaint No. 132/2007 of the State Commission Chandigarh) 1. DR. K.K. SHARMA No.3268,Sector 23-D Chandigarh ...........Appellant(s) Versus 1. FORTIS HOSPITAL Sector 62,Phase VIII,Mohali Chandigarh 2. FORTIS CITY CENTRE SCO 56-57-58, Sector 9-D Chandigarh 3. DR. SANJAY BANSAL NINS BRAIN & SPINE HOSPITAL SCO-341-342, Sector -34 Chandigarh 4. DR. ANUPAM JINDAL NINS BRAIN & SPINE HOSPITAL SCO 341-342 Sector-34, Chandigarh 5. UNITED INDIA INSURANCE CO. SCO 122-123,Sector 17-B Chandigarh 6. THE NEW INDIA ASSURANCE CO. 21,Community Centre New Friends Colony New Delhi ...........Respondent(s)
BEFORE: HON'BLE MRS. M. SHREESHA, PRESIDING MEMBER
For the Appellant : MR. DEEPAK ARORA For the Respondent : Mr. Arun Arora, Advocate &
Ms. Preeti Thakur, Advocate for R-1 & 2.
Mr. K.G. Sharma, Advocate &
Mr. S.K. Roy, Advocate for R-3 & 4 with
Dr. Anupam Jindal, R-4, in person.
NEMO for R-5 & 6.
Dated : 17 Mar 2016 ORDER
Aggrieved by the order in Consumer Complaint No. 132 of 2007 on the file of State Consumer Disputes Redressal Commission, UT Chandigarh (for short "the State Commission"), this Appeal has been preferred by the Complainant under Section 19 of the Consumer Protection Act (for short "the Act"). By the impugned order, the State
Commission held that there was no negligence on the part of the Opposite Party Hospitals and dismissed the Complaint.
2. The brief facts as stated in the complaint are that the Complainant's father was injured in a roadside accident on 31.12.2005 and sustained head injury and fracture on the left leg. Without any loss of time, the Complainant took him to NINS Brain & Spine Hospital, Chandigarh and then to Fortis Hospital at Mohali but the Patient died on 16.02.2006 after 46 days of the accident. The Complainant pleaded that Hospital-induced causes were responsible for the formation of pus in the brain, lungs, liver and other organs which led to septicemic shock which is clearly established in the post-mortem report. The post-mortem report mentions the cause of death as head injury and septicemic shock. Complainant averred that this septicemic shock is most commonly caused by infections due to gram negative bacteria (also called Rods) like E.coli, Klebsiella, Proteus and Pseudomonas and that it has a very high mortality rate.
3. It is pleaded by the Complainant that he had given first-aid to the Patient and immediately shifted him to Dr. Sandhu's Pathology Lab. & Imaging Centre where his X-rays were done and blood tests were taken and plaster was applied to broken leg and after that he was shifted to NINS Brain & Spine Hospital where a CT Scan of his head and brain was done, which showed bleeding in his brain (Haematoma Frontal Region). He was treated by Dr. Sanjay Bansal, neurosurgeon. The treatment of head injury was started. The second CT scan was taken on 02.01.2006 and the third on 04.01.2006 which showed increase in haemotoma and its extension to the intra-ventricular region of the brain. The Complainant was assured that his father would recover within a few days as all the vital parts of the brain including thalamus region and internal capsule region were not involved in the injury. On 06.01.2006, when the sensorium of the Patient started deteriorating, the treating neurosurgeons advised the Complainant to shift his father to a better management centre where there was ventilator support and therefore, the Complainant shifted the Patient to Fortis Hospital, Mohali.
4. It is averred that the Patient was admitted in Specialty Intensive Care Unit of Fortis Hospital on 06.01.2006 under the treatment of Dr. Anupam Jindal, neurosurgeon. He was one of the co-owners of the NINS Brain and Spine Hospital where the Patient was admitted earlier. The bacteriological monitoring of the Patient was done by taking his urine culture test, blood culture test, tracheal-secretions culture test and I/V line tip culture test etc. which did not reveal any kind of infection. On 07.01.2006 the Patient's blood pressure was falling and there was also decrease in his urine output for which he was given a number of blood transfusions and within 3/4 days he recovered and stabilized. After the Patient was stabilized, he had undergone tracheostomy on 11.01.2006. It is stated that he contracted infection of Klebsiells Oxytoca in his trachea during the said operation.
5. The Complainant pleaded that the tracheal secretions culture test which was done on 06.01.2006 and its report on 07.01.2006 did not show existence of klebsiella oxytoca in his trachea. It was only after 11.01.2006 subsequent to the tracheostomy operation of the Patient that the tracheal secretions culture test showed klebsiella oxytoca bacteria in the Patient's trachea. This infection was resistant to most of the antibiotics and was only sensitive to 3 antibiotics. To treat this infection injectable drug called piperacillin-tazobactum was started on the Patient on 14.01.2006 and was continued for 16 long days till 29.01.2006 but the infection could not be eradicated and another deadly bacteria called pseudomonas aeruginosa developed. It is pleaded that these Hospital-derived infections which led to septicemic shock and then the death of the Patient. On 20.01.2006 fungal infection of yeast species was also contracted which led to Systemic Inflammatory Response gradually killing the Patient due to septicemic shock.
6. It is pleaded by the Complainant that no scientific and serious efforts were taken to eradicate this fungal infection from the blood of the Patient which occurred also on account of worsening bed sores which developed on his back and in the gluteal region. No specific treatment was given to the Patient for the bed sores. These bed sores occurred due to sub-optimal hospital care and also poor nursing care rendered to the Patient. The drug "Amphotericin B" is the 'Gold Standard' in the treatment of life threatening systemic fungal infections since resistance to this drug is rare. It is also a drug of choice to treat the most common yeast infections. Moreover, when fungal infections occurred in I/V lines, I/V Canulas and Arterial Canulas etc. they are to be changed at new sites which was not done. When one deadly infection was already contracted by the Patient in the Hospital, extraordinary care should have been taken but unfortunately another deadly infection was given to the Patient which killed him.
7. The post-mortem of the deceased done on 16.02.2006 showed the following:-
"-- A large fracture in the skull of the patient.
-- Fracture both bones of left lower leg of the patient.
-- Pus in the brain of the patient.
-- Pus in the lungs of the patient.
-- Pus in the liver of the patient.
-- Congestion in the meninges (brain coverings) of the patient.
-- Congestion in the kidneys of the patient.
-- Congestion in the spleen of the patient.
-- Congestion in the pleural cavities (lung coverings) of the patient.
-- Huge bedsores in sacral region and right gluteal region including right thigh of the patient.
-- However, heart and pericardium of the patient was normal."
-- Mouth, food pipe, stomach, intestines and peritoneum (inner abdomen covering) of the patient was normal.
The cause of the death was mentioned as head injury with associated Septicemic shock."
8. The Complainant pleaded that his father was a highly educated, health conscious, well-built and mentally fit person who used to walk 8-10 kms per day with no complications regarding his blood sugar levels, lipid profile, kidney functions, liver functions etc. and therefore, had the Hospital taken proper care of him, he would not have developed Hospital-derived infections and died of septicemia. Hence the complaint seeking directions to the Opposite Party to pay ₹30,00,000/- towards compensation apart from interest and costs.
9. Opposite Parties no.1 and 2 representing the Hospital averred that the patient had come to the Hospital, on 06.01.2006 due to deterioration in Sensorium (meaning that the consciousness levels of the patient were deteriorating) due to head injury for which a prolonged ventilation and Intensive Care Unit (ICU) care was required. The patient was in an unconscious state which is evident from the Glasgow Coma Scale (GCS) score of 4/15. This indicated poor prognosis as the patient was a known case of diabetes and multiple fractures on one leg. The patient was suspected to have aspiration pneumonia at the time of admission in the Emergency of the Hospital. For a healthy person, the GCS score is 15/15 and a score near to the minimum level suggests that the patient is having a very poor Neurological status. He had bilateral crepitations (abnormal Breath sounds in the chest elicited with stethoscope) in the chest at the time of admission. This shows severe infection in the chest and the patient was shifted to have aspiration pneumonia. It is averred that the patient had bedsores on the left thigh and in addition to this he was anaemic (Hb 7.3 gms% against a normal value of 12 gms%), low albumin levels (2.7 gms % against a normal value of 3.5 gms % ), hypernatremia (sodium levels were high) and coagulopathy (boold clotting was poor) at the time of admission. All these are signs of grave physical condition with poor prognosis in case of road side accident with head injury, diabetes, hyper tension along with fracture of both bones on the left leg and age of 86 years.
10. It is pleaded that at the time of discharge from the Hospital, the patient was hemo dynamically stable and chest was clear on clinical examination and patient was afebrile (had no fever) and tolerating Ryle's tube feed which shows that he was not in septimic shock but was deeply comatosed. It is also averred that severe head injury in elderly (>65yrs) has a very poor outcome. Textbooks describe mortality (death rate) in such cases anywhere between 70-100%. Outcome in patients over 80 years is even worse and it is recommended not to treat such patients aggressively due to very high mortality and severe disability. Patients with severe head injury frequently develop respiratory complications (incidence up to 60%) and resulting into pneumonia, respiratory failure and septicemia. Twenty five percent of all deaths (in severe head injury) are attributable to respiratory complications. The life expectancy of the patient after head injury, at the age of 86 years is only 2.5 years which comes to 88.5 years and not 100 years as arbitrarily claimed by the complainant.
11. It is denied by the Hospital that the patient contracted infection of Klebsiella Oxytoca during the procedure of Tracheostomy and submitted that the procedure was performed in a clean operation theatre and that the TLCs were monitored and it came down from 14000 cells/cuml to 8100 cells/cuml. After performing Tracheostomy the culture of tracheal secretions showed the growth of Klebsiella Oxytoca which was sensitive to the anitibiotices Meropenem, Imipenem and Piperacillin - Tazobactum. So the Piperacilin was started for 16 days which is an antibiotic and the patient's condition remained stable. They denied that the antibiotic Pactum 4.5 gms was not effective and averred that there was no need to change antibiotics as the patient was not running any fever and his tracheal secretions reduced which assisted in weaning off the patient from the ventilator. All these signs showed that the patient was responding to Pactum 4.5 gms. And ikt was continued as Pactum is also the least nephrotoxic of all the drugs available for use. The antibiotics were later changed to ciproflox and gentamycin when culture showed Pseudomonas and KI oxytoca with changed sensitivity pattern. In clinical practice the basis for the decision to change the antibiotic is not the medical report/test only, of the patient, but also his clinical symptoms, which was emphatically followed in this patient, for the best possible outcome, in this patient. It is an established fact that various gram negative baclli become a part of hospital bacterial flora which may result in colonization of various mechanical devises such as ventilator and which can serve as a risk factor for acquiring infections. All the protocols for a patient on ventilator such as usage of disposable sterile breathing circuits and usage of disposable filters and disposable suction catheters is a practice strictly followed in the answering respondent hospital. However, despite stringent precautions it is not possible to achieve zero percent infection rate in patients on ventilators anywhere in the world. It is, further, pleaded that there was no evidence of life threatening fungal infection, so Amphoterician - B was not given to the patient and fungal culture was not done. His temperature, TLC, blood pressure and blood sugar all remained stable. Treatment option with Amphotericin - B was not exercised in view of very high cost of treatment (Rs.6,000/- per day for 4-6 weeks) and also the related nephrotoxicity. After getting the so called infection and the appropriate treatment, patient's all vital parameters remained stable for about 45 days. During this period he never had high grade fever, increase in TLC, fall in BP which are signs of life threatening fungal infections, to justify the change in treatment. The answering respondent took proper care of the Patient and the contraction of the infections by him during his stay in the hospital was not on account of any negligence of the operating doctor or the other medical staff or on account of lack of medical facilities offered by the answering respondents. The Hospital further averred that poor prognosis regarding patient was explained by Dr. Anupam Jindal and on 28.01.2006, the Complainant expressed his desire not to put his father on ventilator which was signed in his own handwriting and is part of the patient's medical record. The patient was shifted back to NINS for nursing and general care. It is pleaded that they are not responsible for the treatment given to the patient after his discharge on 07.02.2006 and his death on 16.02.2006 and submitted that there is no medical negligence on their part.
12. OP-3 Dr. Sanjay Bansal filed his written statement before the State Commission stating that he had treated the Patient conservatively between 31.12.2005 to 06.01.2006 with due diligence, care and caution. He further submitted in the written version that negligence cannot be assumed and that every surgical operation involves risks and merely because a misadventure or mishap occur the Hospital and the doctors cannot be held to be liable.
13. OP-4 Dr. Anupam Jindal also filed his written version stating that he had treated the Patient conservatively between 06.01.2006 to 06.02.2006 and tracheostomy is a bedside procedure which was done in operation theater. It was carried out in a clean, sterile operation theater and there was no chance of introducing any infection in the surgery. The Patient required tertiary care unit with ventilator and tracheotomy, so he was shifted to Fortis Hospital on 06.01.2006 and remained there till 06.02.2006 and then shifted back to NINS Hospital for nursing care between 07.02.2006 till his death on 16.02.2006. It is stated that septicemia has three main reasons: (a) host factors, (b) the virulence of innate organisms and present commonsel organisms in the body of person itself and (c) Hospital-induced infection. The Patient was 86 years old and could have contracted septicemia after a head injury and immobility due to several inherent reasons of low immunity. The Patient was given treatment with due care and caution. Klebsiella Oxytoca is not an infection, which can be introduced by the doctors in trachea but occurs because of immobility, low immunity, head injury and fractures. Likewise doctors did not introduce aeruginosa and it also occurred only due to immobility, low immunity, head injury and fracture. The Complainant is a doctor and is fully aware of all these reasons. Amphoterecin B was not given because Patient's clinical picture never matched fungimia (fungal infection in blood).
14. The 4th Respondent further averred that the Patient developed huge bed sores of 10 c.m. x 8 c.m. size on the sacral region, bedsores of 6 c.m. x 8 c.m. size on his right gluteal region (buttocks) including right thigh and bed sores on left gluteal region including left thigh not because of lack of care but because of immobility and injury to leg and brain. During the first two days of his treatment, he was semi-conscious and later went into coma. He was shifted to Fortis Hospital on 06.01.2006. The Patient was being religiously turned on his sides and dressings were applied on the bed sores. The Patient was shifted back to NINS Brain and Spine Hospital on 07.01.2006 in the ambulance of Fortis Hospital and was admitted there under Dr. Anupam Jindal who was his primary treating neurosurgeon at the Fortis Hospital basically for nursing care. It is stated in his written version that subdural hematoma was never seen in scans and that lungs and liver full of pus on culture-sensitivity - but these tests usually take 48 hours and that Fortis Hospital does not have OT cultures negative on records on the day of tracheostomy and submits that there is no negligence on their behalf and all care and caution was taken during the treatment of the Patient.
15. The Insurance Company filed their version stating that the Complainant failed to prove by way of any documentary evidence that there was negligence and that the terms and conditions of the policy namely "Professional Indemnity Policy For Doctors & Medical Practitioners" does not cover such cases where a serious allegation is made by the Complainant against the Hospitals/doctors and that no liability could be fastened on them in such cases.
16. The State Commission observed as follows:-
"Now further question to be seen is how the patient contracted fungus infection like yeast in his blood which is called opportunistic infection. It is known fact that immobile patients do not have adequate immunity to fight diseases and got comminuted organisms which are routinely found in our body but do not cause infection like yeast. In case of hospital acquired infection there is always irreducible minimum rate of infection which exists. The ICU patients are thus prone to these types of fungus like yeast. Blood culture of Sh. S.N. Sharma showed yeast and he was put on Fluconazole - one of the antifungal drugs. However, his condition never matched that of fuingimia - fungal infection in blood resulting in severe drop in blood pressure, high grade fever and increase in TLC), so no further investigations like fungal culture sensitivity were carried out as it would have been out of context as the patient was stable and showing progressive improvement after the detection of yeast in the blood, therefore, aggressive treatment was not given. There was no evidence of life threatening fungal infection. All vital parameters of Sh. S.N. Sharma remained stable for about 45 days because during this period he never had high grade fever, increase in TLC, fall in BP which were signs of life threatening fungal infection to justify the change in treatment. Hence, it cannot be said that he had contracted infection due to negligence of the operating doctor or other medical staff or on account of lack of medical facilities offered by OPs. It was also stated by OPs No. 1 & 2 that the hospital had done all what was possible to control the hospital acquired infection and there was no question of medical negligence on their part. 33. As far as the growth of bedsores are concerned there is no denying the fact that in addition to the severe head injury he had fracture of both bones of left leg for which POP cast was applied to mid thigh as initial first aid. This did not allow patient to be placed in full lateral position which was required for the prevention of bedsores. It was contended by counsel for OPs that all the precautions were taken like changing his position two hourly and placing him on air mattress to avoid bedsores but despite all these measures some of these comatose patient developed bedsores and their incidence was never zero especially with prolonged coma like situation as in this patient. They further stated that Dr. N.C. Raina was consulted for the bedsores and appropriate action was taken and two times dressing was done with antibiotic cream and debrided regularly. Further as per their opinion non aggressive approach was used. It was stated by Dr. Jindal that the patient had a febrile position till 14.02.2006 when he developed fever. His culture was sent and revealed a change in the sensitivity pattern and his antibiotics were changed accordingly but his condition deteriorated on 15.2.2006 and he died on 16.2.2006 morning.
34. Counsel for OPs contended that the death of the patient occurred due to severe head injury and its resultant complication-chest infection-septicemia and not due to Kiebsiella Oxytoca and fungus of yeast. The complainant has not produced any expert independent evidence to prove his allegations.
35. It was also contended that since complainant had filed petition under Motor Vehicles Act for the injuries and death caused by accident before the Motor Accident Claims Tribunal and as such the complaint under Consumer Protection Act is not maintainable on the ground of medical negligence. In our opinion, the contention of learned counsel is not tenable because claim under Motor Vehicles Act for the injuries caused by rash and negligent driving by the driver of a vehicle is different than negligence caused to the patient in his treatment. We are supported in our view by the authority of Hon'ble National Commission titled Shridevi Hospital and Shridevi Diagnostic & Research Centre & Anr. Vs. P. Subhash 2007 (1) CPC - 446. In the said authority it was observed that complaint is maintainable in spite of the fact that complainant had also filed petition before the Motor Accident Claims Tribunal for rash driving because under Section-3 it is an additional remedy.
36. Therefore, in view of the discussion above, we hold that complainant has failed to prove that there was any negligence or deficiency in service on the part of OPs or staff of the hospital in causing any type of infection to Sh. S.N. Sharma and as such complaint is dismissed."
17. Aggrieved by the said order the Complainant preferred this Appeal.
18. Heard both the sides at length.
19. The brief point that falls for consideration is whether Complainant's father i.e. the Patient who was 86 years old; suffered a head injury in the accident; was admitted in Fortis Hospital on 06.01.2006 and discharged on 06.02.2006; died in NINS Hospital on 16.02.2006 was on account of Hospital-derived infections and if so, did the infection occur on account of the negligence of the Hospital/doctors/staff?
20. A brief date-wise synopsis is as follows:-
i. On 31.12.2005:- In a road accident Patient Sh. S.N. Sharma suffered head injury and fracture.
ii. On 31.12.2005:- Patient was taken to Dr. Sandhu Pathological and Imaging Centre.
iii. From 31.12.2005 to 06.01.2006:- Patient was treated at NINS Hospital.
iv. From 06.01.2006 to 06.02.2006:- Patient remained admitted in Fortis Hospital. Tracheostomy Operation was done on 11.01.2006.
v. On 07.02.2006:- Patient was shifted from Fortis Hospital to NINS Hospital.
vi. On 16.02.2006:- Patient passed away in NINS Hospital.
21. It is an admitted fact that the Complainant's father was 86 years old and met with a serious road accident and suffered head injury involving fracture of skull extending from front to back of the head and haemotoma of right side of the brain with subarachnoid hemorrhage. The discharge summary dated 06.01.2006 of NINS Brain & Spine Hospital states as follows:-
Patient was admitted with history of RTA, hit by a scooter. Broken left leg already with plaster.
Patient in semi-conscious state.
Known case of DM & HT under control.
? CAD.
CT scan was taken on 31.12.2005 which showed right frontal region haemotoma.
CT scan was repeated on 02.01.2006 which showed increased in haematoma.
< >
Patient went into coma on 02.01.2006.
Patient referred to higher institution for further management.
At the time of discharge Patient's condition was unconscious, not responding to any verbal or painful stimuli.
B.P. 126/48 mmhgGCS: E1V1 M2-3
PR. 118/minute
Chest - B/L - Crapts +
TLC at the time of discharge 9400 cmm and RBS 140 mg/dl.
22. The aforementioned document evidences that by the time the Patient reached Respondent Hospital he was in a state of coma and was not responding to any verbal or painful stimuli and had infection in the lungs. In that current situation he could be termed as a high-risk patient being 86 years old having suffered a head injury and already in coma. The report dated 06.01.2006 does not show any significant growth of bacteria in the blood culture. A brief perusal of the progress notes from 06.01.2006 till 08.01.2006 shows in detail the protocol maintained with respect to administering of medicines and investigations done.
23. It is the case of the Appellant/Complainant that sepsis developed in the Patient at Respondent Hospital and in fact the progress notes dated 07.02.2006 shows "? Sepsis" which indicates that the treating doctors were in the knowledge of a possible development of sepsis, but did not take appropriate steps to curtail it and that the very sepsis developed because of the negligent treatment by the Respondents herein. Learned counsel for the Appellant/Complainant submitted that the Respondents were negligent on four counts:
Infection of Klebsiella Oxytoca in the Trachea of thepatient around 11.1.2006
Fungal infection in the blood of the patient on 20.1.2006.
Infection of Pseudomonas Aeroginosa on 2.2.2006.
Multiple bed sores full of dead tissues not attended to despite ICU call.
Learned Counsel for the Appellant/Complainant contended that it was five days after the Trachea was done that culture showed growth of Klebsiella Oxytoca which was not controlled even after 10 days and a repeated culture test done on 02.02.2006 showed mixed growth of Pseudomonas Aeroginosa and Klebsiella Spp. He submitted that the fungus infection in the blood along with aforementioned fungal infections occurred one after another which led to multiple organ failure and septicaemic shock. He, further, contended that in the diagram of bedsores, it was written "slough +ve, needs debridement" (means bed sores full of dead tissues and are leaking, they need surgical cleaning of dead tissues); that Dr. N. C. Rania was called for but he never attended to the patient. The patient was regularly running fever due to infections and was given paracetamol and the antibiotics which were administered did not control the fever.
24. The Appellant argued that Fortis Hospital did not have any proof to show that culture tests of Operation Theatre equipment/environment were negative on the date of operation (means no proof to show that OT was free from infectious organisms) and that septicemic shock had nothing to do with the accident and is only the result of multiple hospital acquired infections.
25. The discharge summary of Fortis Hospital dated 07.02.2006 shows that all investigations in terms of blood, urine, CT scans and X-rays of the fractured parts were done and the Patient was incubated and put on the ventilator on 06.01.2006; tracheostomy was done on 11.01.2006. Pages 226 to 256 are all enclosures of the discharge summary which show the tests undertaken, the results from 06.01.2006 to 07.02.2006. On 04.02.2006 tracheal secretions was done and CT scan was done on 06.02.2006 which showed right frontal bleed with surrounding oedema causing effacement of right lateral ventricular atria. Hypodensity seen in left occipital lobe - likely counter coup contusion. Small Etra axial haematomas are noted in left temporal and right occipital region. Posterior fossa structures appear normal. No evidence of midline shift and a fracture right frontal bone, right high parietal bone and inner table of left high parietal bone. The Respondent Hospital relied on medical literature which the Complainant himself had filed wherein in page 92 Klebsiella bacteria infections are specified. Klebsiella pneumoniae could be a Hospital-derived infection, but it is an admitted fact that the Patient was suffering from aspiration pneumonia which is caused by klebsiella pneumoniae and was also diagnosed as a patient of bronchial asthma. Immediate treatment was provided to the Patient with Piparcillin Tazobactum and TLC level came within range.
6.1.2006 The patient was put on mechanical Ventilation on 6.1.2006
(The Treachael Secretions culture hsows mixed bacterial growth of no significance after overnight incubation at Page 81) This report needs to be read with physical examination of the patient with showed Bilateral Crepitations _ve (Page 76 bottom) B/L Basal Crepts (Page 225 5th line from bottom) and TLC level of 9,900 on 5.1.2006 page (Page 77 top 3rd line) TLC White Blood Cells 14,000 (page 228) Haemoglobin 7.3 (low out of range) Prothrombin Time 19.9 Sec (Out of range)
8.1.2006 TLC (Total Leucocytes Count) 22,200 (Page 232)
9.1.2006 TLC : 15,400 (page 234)
9.1.2006 Haemoglobin level of the patient improved to 12 gms (Page 234) (It was 7.3 at the time of admission Page 228)
9.1.2006 Cretinine level 2.2 (Beyond normal range)
10.1.2006 TLC 13,100
11.1.2006 page 240 Prothrombin level became normal to 12.9 seconds
11.1.2006 Tracheostomy conducted
12.1.2006 Tracheal Secretions culture shows growth of Klebsiella Oxytoca (Page 82)
12.1.2006 TLC 8,100
15.1.2006 TLC 10,300
15.1.2006 Cretinine 0.9
19.1.2006 Cretinine 0.8
16.1.2006 Tracheal Secretions showed K. Oxytoca after over night incubation sensitive to Piperacillin Tazobactum (Page 83) Treatment continued with Pipercillin Tazobactum
20.1.2006 Blood Culture showed presence of Yeast SPP (Page 117) which was treated with Fluconazole
20.1.2006 TLC 8,300
02.02.2006 Tracheal Secretions shows mixed bacterial growth of doubtful significance. To be correlated clinically with Pseudomonas Aeruginosa Sensitive to Gentamycin (Page 85) The Patient is immediately treated with Gentamicin
26. Medical Literature by Kathleen R. Bell described Complications associated with Immobility after TBI (Traumatic Brain Injury) as under:-
"Immobilization of the human body has long been known to affect Physiology in ways detrimental to normal function, even in the times of Hippocrates ... As an additional complicating factor in severe traumatic brain injury (TBI), the effects of immobilization may be prolonged and worsened by a number of disorders stemming from brain injury itself such as posturing, spasticity, dysautonomia, endocrine abnormalities and other body system injuries.
...
Therefore TBI patients are already at the risk of pulmonary complications during their rehabilitation. Prolonged bed rest adds to that risk. In healthy individual demonstrates that functional residual capacity of the lungs falls by 33% during this period ... Diffusing capacity decreases ... Pulmonary blood flow also decreases by 16%. All of these changes result in higher risk ... Pulmonary infections. Treatment consists of early mobilization of the patient and aggressive pulmonary toilet with suction. In the present case, the patient was immobile due to multiple fracture of left leg and hence increased risk of infections due to Immobility coupled with Traumatic Brain Injury and Fracture.
The Traumatic Brain Injury coupled with Immobility further affects Integumentary System (Skin) Page 296 backside which states "Pressure ulcers are well known complications of prolonged bedrest. Pressure ulcer are associated with increased mortality, mobidity, length of stay and cost of treatment. ... Immobility and decreased body weight are both independent risk factors for the development of pressure sores.
Page 314: In the Medical literature, Assessment, Early Rehabilitation, Intervention and Tertiary Prevention by W. Jerry Mysiw, Lisa P. Fugate and Daniel M. Clinchot, the studies on prognoses shows that early predictors of Outcome are:-
< > Primary Brain Injury Secondary Brain Injury Glasgow Coma Scale Pupillary response CT Scan Sitting Balance Functional Independence Measure; and Post - traumatic imnesia ....
Page 315 "The type of central nervous system lesion incurred at the time of trauma has been correlated with both survival and functional outcome. Most studies agree that the injury with the highest mortality rate and the poorest functional outcome is the subdural hematoma. "In the present case the post mortem report shows large Sub Dural Hemotama at Page 63 whereas 3 CT Scans at Page 76 shows continuously increasing hemotoma starting from 31.12.2005 to 2.1.2006 when the patient went in Coma.
The medical studies shows at Page 315 that "Both coma duration and coma depth are important markers of injury severity with prognostic implications, but coma duration may be a better predictor of motor and cognitive recovery than coma depth. ....
Patients who remain comatose for greater than 2 weeks rarely achieve a good recovery.
The medical studies relating to Respiratory Disorders at Page 318 state that Respiratory pulmonary complications notes after traumatic brain injury include those directly related to trauma such as pneumothorax, hemothorax and flail chest. In addition, a number of pulmonary complications occur that are at least, in part, related to subsequent neurologic dysfunction, pulmonary edema and tracheal airway complications. Pulmonary complications are the most frequent complications occurring after the acute trauma through the hospitalization stay, with upto 60% of patient experiencing pneumonia, respiratory failure occurring in upto 43% and 39% requiring a tracheotomy.
Page 318 backside. "Approximately 34% of traumatic brain injury survivors develop respiratory complications that predispose them to pulmonary infections.
27. The Hospital treatment record shows in their critical care flowsheet that the following steps for treatment were taken:-
"1. Antibiotics were started and continued in Fortis as Patient was unconscious and also had Diabetes mellitus and hypertension and old age. (page 1 of case sheet back side).
2. Patient's diabetes was managed with insulin infusion which was started on 7-1-6 ( page 6 backside) and later on regular and long acting insulin were given.
3. Inj albumin was given repeatedly as he was not taking anything by mouth and also his gut was not tolerating tube feeds for almost 15 days from his date of injury. Gastro consultation was taken appropriate steps were taken - these are essential steps to build his nutritional status which go a long way to prevent infection and enhance immunity.
4. Chest and limb physiotherapy was done daily regularly - physiotherapy notes can be seen on case sheet on daily basis.
5. Cleaning of equipment used in patient care like drug trolley, bed side locker, oxygen mask, cardiac monitor, suction apparatus, ventilator, syringe pump, ambu bag, ET tube tie were checked and recorded daily in nurses record (in the last part of case sheet). "
Steps taken to prevent blood borne infections Staff and doctors applied antiseptic solution on hands before and after touching each patient in ICU.
Each doctor has only patient to take care to minimize risk of infections.
IV transfusion sets are changed almost daily.
As soon as his blood culture reports were received he was started on Fluconazole (appropriate antifungal) Steps taken to prevent tracheostomy and chest infections Tracheotomy was done in operation theatre with all aseptic precautions.
HME filters (to prevent respiratory secretion to spread to other patients and vice versa) were used and changed frequently Culture sent on 11.1.2006 grew Klebsillae which was treated with according to culture sensitivity reports (Piperacillin - tazobactum) The patient was nebulized 2-3 times a day and chest physiotherapy was done to remove chest secretions Repeat culture showed pseudomonas and klebsilla combined he was started on ciploflox and gentamicin according to culture sensitivity reports only.
No empirical antibiotic was used during hospital stay.
28. It is also the contention of the Respondent Hospital that all necessary care and caution was taken to take care of the bed sores by using alpha air mattresses, changing sides every two hours, dressing to sores done twice daily coupled with surgical consultations. It is also stated that the Hospital staff and doctors applied antiseptic solutions at the hands before and after touching the Patient; IV transfusion sets were changed almost daily; blood culture reports were received and the Patient was started on fluconazole which is antifungal.
29. It is the contention of the Appellant that it is only on account of improper care taken by the Hospital that the Patient had developed bed sores which were improperly treated due to which Hospital-derived infections like Klebsiella bacteria and fungal yeast infections were contracted by the Patient. The brief perusal of the medical record shows that the Patient at the time of admission into Fortis Hospital was in a coma, was in a case of progressive worsening of the sensorium on account of head injury and infection, fractured in both bones in the left leg, was hypertensive, diabetic, had bronchial asthma and bed sores on the left thigh and back. It can be construed that he was a high risk Patient considering his age of 86 years and being in the aforementioned condition at the time of admission into the Respondent Hospital. There is no material on record to establish that the treatment given to the Patient herein was against the norms of normal standard medical parlance. The Hon'ble Supreme Court in a catena of Judgements has held as follows:-
"A medical practitioner is not liable to be held negligent simply because things went wrong from mischance or misadventure or through an error of judgment in choosing one reasonable course of treatment in preference to another. He would be liable only where his conduct fell below that of the standards of a reasonably competent practitioner in his field.
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.
Simply because a patient has not favourably responded to a treatment given by a doctor or a surgery has failed, the doctor cannot be held straightway liable for medical negligence by applying the doctrine of res ipsa loquitur. No sensible professional would intentionally commit an act or omission which would result in harm or injury to the patient since the professional reputation of the professional would be at stake. A single failure may cost him dear in his lapse."
30. Keeping in view that there is no evidence on record to establish that the Appellant Hospital/doctors/staff have been negligent in the treatment of the Patient and also having regard to the fact that the Patient was a 86 year old high-risk Patient who was admitted in the Appellant Hospital in a stage of coma and trauma due to had injury, and all efforts were made in accordance with standards of normal medical parlance, no medical negligence can be attributed to the Respondents. Hence this Appeal fails and is dismissed accordingly. No order as to costs.
...................... M. SHREESHA PRESIDING MEMBER