National Consumer Disputes Redressal
Mamta Bhatt & Anr. vs Dr. Sushila Tiwari Govt. Hospital & 5 ... on 12 May, 2023
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI CONSUMER CASE NO. 637 OF 2015 1. MAMTA BHATT & ANR. ...........Complainant(s) Versus 1. DR. SUSHILA TIWARI GOVT. HOSPITAL & 5 ORS. (THROUGH ITS CHIEF MEDICAL SUPERINTENDENT)
RAMPUR ROAD,HALDWANI, NAINITAL, UTTARAKHAND 2. DR. GODAVARI JOSHI,OBSTETRICS & GYNECOLOGY, DR. SUSHILA TIWARI GOVT. HOSPITAL,
RAMPUR ROAD,
HALDWANI, NAINITAL UTTARAKHAND 3. DR. MONIKA VARSHNEY, KUMAR NURSING HOME,
RAMGHAT ROAD, ALIGARH U.P. 4. DR. SAKSHI AGGARWAL, AGGARWAL CLINIC, KOTDWAR,
PAURI GARHWAL, UTTARAKHAND-246 149. 5. DR. GARIMA SHARMA, MEDICAL OFFICER, B.D. PANDEY MAHILA CHIKITSALYA, MALLITAAL(NAINITAL) UTTARAKHAND-263 001 6. DR. R.C. PROHIT, PRINCIPAL, GOVT. MEDICAL COLLEGE, HALDWANI, UTTARAKHAND ...........Opp.Party(s)
BEFORE: HON'BLE DR. S.M. KANTIKAR,PRESIDING MEMBER
For the Complainant : APPEARED AT THE TIME OF ARGUMENTS
MS. ASTHA TYAGI, ADVOCATE
MS. DIKSHA NARULA, ADVOCATE For the Opp.Party : APPEARED AT THE TIME OF ARGUMENTS
MR. GURVINDER SINGH, ADVOCATE
FOR OP NOS.1, 2, 4 TO 6
MS. SURUCHI AGGARWAL, SR. ADVOCATE
WITH MS. GARIMA BAJAJ, ADVOCATE &
MR. KARAN KUMAR, ADVOCATE FOR OP-3
Dated : 12 May 2023 ORDER
Emergency obstetric hysterectomy (EOH) is generally performed as a lifesaving procedure in cases of rupture uterus, postpartum haemorrhage, morbid adhesions of placenta and uterine sepsis. On one hand, it is used as a last resort to save the lives of mothers and on the other hand women's reproductive capability is sacrificed. Often it is a difficult decision and requires good clinical judgment. The maternal outcome greatly depends upon the timely decision, the surgical skill and the speed of performing the surgery.
1.This Complaint was filed by Complainant No. 1 Smt. Mamta Bhatt & Complainant No. 2 her husband Sh. Sunil Bhatt against Dr. Sushila Tiwari Govt. Hospital, Rampur Road, Haldwani, Uttarakhand and five doctors (hereinafter referred to as 'Opposite Parties') for medical negligence and deficiency in service due to which the Complainants lost their child during delivery and the uterus of the Complainant No. 1 had to be removed.
2. The Complainant No. 1, Smt. Mamta Bhatt, (hereinafter referred to as 'the patient'), was admitted in Dr. Sushila Tiwari Govt. Hospital at Haldwani (OP No. 1- Hospital) on 7.7.2013 at 1.34 am. Her mother in law accompanied her. The patient felt labour pains several times, but no heed was paid to her despite many requests made by the patient's mother-in-law. It was further alleged that for 26 hours after the admission no ultra sound (USG) or other tests were performed. In the early morning at 5.00 a.m. on 08.07.2013, the doctors informed the patient about abnormal foetal heartbeats and caesarean operation was required. It was alleged that the operation was performed by OP Nos. 3 to 5 (Dr. Monika Varshney, Dr. Sakshi Aggarwal and Dr. Garima Sharma), they were junior and inexperienced doctors who performed the operation with the telephonic instructions from OP No. 2 who was not present in the hospital at that time. The newborn died during the operation and the patient also suffered excessive bleeding due to wrong cut. As the patient began to deteriorate, the patient's family members contacted Dr. R.C. Purohit (OP No. 6) who immediately intervened and shifted the patient to I.C.U. Due to heavy bleeding, the patient was in shock. The doctors hurriedly without ascertaining the cause of bleeding performed hysterectomy. A total 8-9 unit of blood was administered. The cause of death of the new born was stated to be due to entangled umbilical cord around the neck. The patient was discharged from OP No. 1 Hospital on 20.07.2013.
3. An enquiry committee was set up by OP No. 6 to look into matter of negligence and deficiency in service. The instant case was widely reported and covered in various newspapers. The Complainant No. 1 through RTI got the report of Enquiry Committee and the medical records from the police department. Being aggrieved, the Complainants (1 & 2) filed the Consumer Complaint against the Hospital (OP-1) and the treating doctors for medical negligence and deficiency in service.
DEFENCE:
4. The Opposite Parties filed their respective Written Versions and denied the allegations of medical negligence. The preliminary objection was that the patient was not consumer under the Act, 1986 because the entire treatment was done in a Govt. Medical College and no consideration has been paid by the Complainant. The Complaint was filed beyond limitation of two years of cause of action. Moreover, the Complaint pleadings were not signed by the Complainants before filing in this Commission, but it was signed by the Advocate who has no right and it was illegal. The OPs relied upon the few standard text books namely 'Clinical Obstetrics' by Mudallar & Menon, Text Book of Obstetrics by CS Dawan, William's Obstetrics and Munro's practical Obstetrics.
5. Dr. Monika Varshney (OP-3) filed her separate written version and submitted that she had no privity of contract and no direct 'consumer' relationship within the meaning of Act, 1986. The patient was treated at OP-1 Govt. Hospital free of charge. During operation she found the blood clots in the retroplacentally and three rounds of umbilical cord around the neck of the baby, therefore, baby could not be saved and emergency hysterectomy operation was performed in presence of Dr. Godawari who was present in the OT at the time of closure. The OP No. 3 submitted that two operations were performed. The first operation was done by the OP No. 3 and the 2nd operation of hysterectomy was done by the Senior Consultant. As per records as well as the reports of the expert committee, the baby had lost its life due to 'Retroplancental Haematoma' (blood clot) and due to obstruction of throat because of three rounds of cord. Thus, it was not negligence.
6. Heard the arguments from both the sides and perused the material on record.
7. The Complainant was full term primi gravida admitted in Obstetrics ward at OP-1 on 07.07.2013. All the relevant lab tests were done and she was Rh-negative. The blood was kept ready after cross match. The progress of labour was continuously monitored and there was no indication for emergency caesarean section. The condition of patient and foetus was normal. The informed written consent was taken in HINDI and it was signed by her mother-in-law Saroj. As labour pain increased and FHS suddenly dropped, therefore, at 4.30 p.m. the decision was taken to proceed with Caesarean Section. The Caesarean operation was completed at 6.15 am but the foetus could not be saved due to three tight loops of cord around the neck and retro-placental haemorrhage.
8. After the operation the patient was shifted to postoperative recovery ward. The patient complained of Palpitation and Ghabrahat at 9.15 am. Immediately senior Obstetric Consultant and Associate Professor on duty Dr. Godawari Joshi ( OP2) examined the patient and diagnosed it as a case of Atonic PPH. Then OP2 informed the HOD Dr. R.C. Purohit (OP-6) and all conservative measures were tried to control PPH. The l ifesaving B-negative blood, was transfused as arranged from the hospital. When all conservative Medical and surgical methods failed to control bleeding, therefore emergency Hysterectomy was performed.
ARGUMENTS:
9. Arguments on behalf of the Complainant The learned Counsel for the Complainants vehemently argued on maintainability of the complaint. Firstly whether Complainant was a "Consumer". It is pertinent to note that the OPs have raised a bill for Rs.13,689/-, which also includes service charges of Rs.960/- along with other charges. Therefore, in my view the Complainant is a consumer as defiled u/s 2(1) (d) of the Act. Secondly, I note the Complaint was not barred by limitation as the cause of action arose on 08.09.2014 when the Complainant got the copy of the first enquiry committee through RTI from the police department. The instant complaint was filed on 15.07.2015, i.e. well within two years -the period of limitation.
10. The learned Counsel further argued that, the written consent was not obtained at the time of admission. The Committee pointed out deficiency in service and negligence at various stages of the treatment by the OPs. Thereafter, Prof. R.C. Purohit (OP-6) in order to safeguard the interest of OP No. 1 to 5, appointed another committee comprising Dr. Smt. Devnanda Chaudhary (Prof Gynaecology and Obstetrician) Dr. Anjali Nautiyal (Gynaecologist ). The said committee gave a non-speaking order absolving the Opposite Parties of any negligence.
11. Arguments from the Opposite Parties No. 1, 2, 4 to 6 The learned Counsel for the Opposite Parties argued the complainant has not filed cogent evidence to prove negligence of the OP Nos. 1, 2, 4 to 6. Entire treatment was done in a Govt. Hospital of state of Uttarakhand under the Janani Shishu Suraksha Karyakaram (JSSK) scheme started for the welfare of the general public and free treatment of all pregnant women under the Ministry of Health & Family Welfare, Govt. of India.
12. Arguments from the Opposite Party No. 3The learned Counsel for the OP-3 vehemently argued that Dr. Monika (OP-3) was a Post Graduate, Senior Resident and not an employee of the OP No. 1 hospital as such would not fall under the ambit of Section 2(1)(d). Her role was very limited. The learned Counsel placed reliance upon the judgments of the Hon'ble Supreme Court in Samira Kohli v. Dr. Prabha Machanda[1] and Martin F. D'Souza v. Mohd. Ishfaq [2] FINDINGS & DISCUSSION:
13. I have gone through Medical literature on the subject of normal delivery, the PPH and its management. Also perused William's Obstetrics and Text book by Dr. D.C. Dutta.
Postpartum haemorrhage (PPH):
Obstetric haemorrhage is associated with increased risk of serious maternal morbidity and mortality. Postpartum haemorrhage (PPH) is the commonest form of obstetric haemorrhage, and worldwide, approximately every 4 min a woman dies due to massive PPH. As per WHO the PPH is generally defined as blood loss greater than or equal to 500 ml within 24 hours after birth, while severe PPH is blood loss greater than or equal to 1000 ml within 24 hours. Most cases of morbidity and mortality due to PPH occur in the first 24 hours following delivery and these are regarded as primary PPH whereas any abnormal or excessive bleeding from the birth canal occurring between 24 hours and 12 weeks post-natally is regarded as secondary PPH.
PPH may result from failure of the uterus to contract adequately (atony), genital tract trauma (i.e. vaginal or cervical lacerations), uterine rupture, retained placental tissue, or maternal bleeding disorders. Uterine atony is the most common cause and consequently the leading cause of maternal mortality worldwide. As per the WHO recommendation if the bleeding does not stop in spite of treatment with uterotonics, other conservative interventions (e.g. uterine massage), and external or internal pressure on the uterus, surgical interventions the utero-ovarian and hypogastric vessel ligation may be tried. If life-threatening bleeding continues subtotal or total hysterectomy should be performed.
Postpartum Hysterectomy:
Postpartum hysterectomy refers to hysterectomy done e. ther after vaginal delivery or caesarean delivery. In modern obstetric practice, it is a major operation being associated with a high rate of morbidity and mortality. The major indications for emergency postpartum/obstetric hysterectomy (EOH) include placenta previa; placenta accreta, increta, and percreta; and uterine rupture. Thus, most of such hysterectomies are unplanned and often performed as an emergency for obstetric haemorrhage which doctors are unable to stop or there is undiagnosed abnormal placentation. The most common indication of EOH was uterine atony (25%) followed by morbidly adherent placenta (21%) and uterine rupture (17%).In spite of the availability of uterotonics agents and a variety of uterus sparring surgical interventions, the obstetrician will be faced with the dilemma to choose a conservative or an aggressive management. The treating doctor/surgeon is sometimes in a dilemma whether to sacrifice a woman's reproductive capability especially if she is of low parity. It also depends upon the woman's desire for preserving fertility but further delay in emergency postpartum hysterectomy may lead tosevere morbidity or maternal death. If all attempts at arresting bleeding have failed, subtotal or total hysterectomy is attempted as a last resort and life-saving measure.
The preoperative risk factors include previous history of caesarean section, placenta previa and accreta. Obstetric shock index may help in avoidance of under estimation of blood loss and the use of tranexamic acid, oxytocic and timely peri-partum hysterectomy will help to save lives. Due to the complexity of the surgery and decision making, the involvement of an experienced obstetrician at an early stage is desirable.
The life-threatening haemorrhage i.e. in cases of haemodynamic instability the decision to perform a hysterectomy should not be delayed. Therefore subtotal hysterectomy is preferred because it is associated with minimal risk of visceral injuries and blood loss. It needs short operating time and hospital stay. It is known that women with abnormal placental adhesion were approximately two times more likely to undergo total than subtotal hysterectomy. The decision to escalate surgical management to hysterectomy should be made by the most senior and experienced obstetrician.
14. In the instant case, it is evident from the medical record that the patient was admitted on 07.07.2013 at 1.30 am for normal delivery. Due to increasing pain the senior emergency consultant Dr.Godavari Joshi directed for Caesarean operation on 08.07.2013. It was performed by Dr. Monika Varshney under care of O.P. No.3 in the early morning. At the time of operation blood clots were present retroperitoneally and three rounds of umbilical cord around the baby's neck. Therefore baby could not be saved. Secondly the patient was transfused B-Neg blood, but due Atonic PPH there was intractable obstetrical haemorrhage thus, to save the life of patient an emergency hysterectomy was performed. In my view, there was no deviation of standard of practice from the treating doctors at OP hospital.
15. I would like to rely upon the decision of Hon'ble Supreme Court in Jacob Mathew v. State of Punjab[3] which followed the Bolam's principles and observed that;
"25......At times, the professional is confronted with making a choice between the devil and the deep sea and he has to choose the lesser evil. The medical professional is often called upon to adopt a procedure which involves higher element of risk, but which he honestly believes as providing greater chances of success for the patient rather than a procedure involving lesser risk but higher chances of failure. Which course is more appropriate to follow, would depend on the facts and circumstances of a given case. The usual practice prevalent nowadays is to obtain the consent of the patient or of the person in-charge of the patient if the patient is not be in a position to give consent before adopting a given procedure. So long as it can be found that the procedure which was in fact adopted was one which was acceptable to medical science as on that date, the medical practitioner cannot be held negligent merely because he chose to follow one procedure and not another and the result was a failure."
Further in the case of Achutrao Haribhau Khodwa v. State of Maharashtra[4] wherein the Hon'ble Supreme Court observed as:
"The skill of medical practitioners differs from doctor to doctor. The very nature of the profession is such that there may be more than one course of treatment which may be advisable for treating a patient. Courts would indeed be slow in attributing negligence on the part of a doctor if he has performed his duties to the best of his ability and with due care and caution. Medical opinion may differ with regard to the course of action to be taken by a doctor treating a patient, but as long as a doctor acts in a manner which is acceptable to the medical profession, and the Court finds that he has attended on the patient with due care skill and diligence and if the patient still does not survive or suffers a permanent ailment, it would be difficult to hold the doctor to be guilty of negligence."
16. Based on the discussion above, the treating doctors at OP-1 hospital have not failed in their duty of care and they have treated the patient as per the reasonable standard of practice. The death of baby was not due to negligence and to save the life of patient, the decision of emergency hysterectomy was correct.
17. Therefore, obtaining facts and circumstances, I do not find it feasible to attribute negligence / deficiency on the opposite parties. The Complainants have failed to prove deficiency / negligence against the hospital and the treating doctors.
The Complaint is dismissed. There shall be no order as to costs.
[1] (2008) 2 SCC1 [2] (2009) 3 SCC 1 [3] (2005) SSC (Crl) 1369 [4] (1996) 2 SCC 634 ............................... DR. S.M. KANTIKAR PRESIDING MEMBER