Bombay High Court
Dr. Ravindra Kulkarni vs Mr. Balasaheb Gangaram Gavade on 14 January, 1999
Equivalent citations: 1999(4)BOMCR58
ORDER
A.A. Halbe, President.
1. This appeal by the appellant Dr. Ravindra Dattatraya Kulkarni is directed against the order of the Additional District Forum, Pune in Complaint No. 311 of 1995, directing the appellant to pay Rs. 2,50,000/- with 18% interest thereon from 28-12-92 till payment on the ground that the appellant has been grossly negligent in the treatment of wife of the complainant by name Charulata Balasaheb Gawade, when she delivered the female child on 28-12-92 in the hospital of the appellant. The main grievance is that after the delivery by Charulata, the appellant did not attend on her. There was profuse bleeding from uterus soon after the delivery and that in spite of repeated complaints made by Charulata and her attending relations, no attention was paid and lastly when the doctors arrived, the situation had gone out of control and ultimately, in the evening hours of the same day, Charulata died. She was aged 27 years and had two children. She was working as a Teacher on the salary of Rs. 4,000/- per month and in absence of the wife, the complainant was entitled to compensation, which was quantified around Rs. 5,00,000/-. The District Forum in its elaborate judgment found fault with the appellant. The District Forum concluded that this was a case of Post-mortem Haemorrhage and not a case of 'Disseminated Intravascular Coagulation (D.I.C.) leading to cardiac arrest. The District Forum calculated the damages at Rs. 2,50,000/-, which we believe are not based on a particular formula, namely the multiplier about the future life of the wife, loss of consortium to the husband and loss of life to the family. Anyway the compensation has been quantified at Rs. 2,50,000/- by the District Forum. It is against this order, that the appellant doctor preferred this appeal and the main contention of the appellant is that this was not at all Post Partum Haemorrhage, but a case of Disseminated Intravascular Coagulation, which is not predictable. The death was essentially on account of massive pulmonary embolism and there was no Histo-pathological examination of the viscera sent to the analyser. The certificate of Dr. L.K. Bade, Professor and Head of the department of Forensic Medicines of B.J. Medical College, Pune dated 13-3-95, suggestive of death due to Post-Partum Haemorrhage is not based on scientific data. No recognizable poison was detected in the exhibit sent for chemical analysis by the chemical analyser to the Government.
2. We may briefly state that the District Forum has chosen to rely on the opinion of Dr. Bade and the story narrated by the complainant and his relation, which was to the effect that the deceased was not attended to in time although she was bleeding profusely from uterus and was complaining of abdominal pain all along from 3.30 p.m. to 4.30 p.m. on 28-12-92. The District Forum totally ignored the affidavit of the co-patient Smt. Lalabai Ramchandra Tapkir on the ground that her affidavit was a concocted document and did not bear the signature. The District Forum also refused to believe the story of the appellant that at the time of delivery, the appellant was busy in attending the emergency case of curetting of one Mrs. Sathe. The same was not mentioned in the F.I.R. of the police and post mortem report. The same was also not borne out from the case papers. The District Forum laid emphasis on the finding that the uterus was found to be flabby containing large clots of blood indicating that there was profuse bleeding, which resulted in the death of Charulata. Some facts are also narrated to show callousness on the appellant in attending Charulata. This therefore makes imperative on us to probe through the facts and the evidence on record.
3. To narrate few facts, we find that Charulata was under the treatment for future pregnancy with the appellant. She was registered as a patient with the appellant on 23-6-92 in the Kulkarni Hospital at Pune. She was under the advise and consultation of the appellant and on 14-12-92, the appellant advised ultra-sonography. During the sonography it was certified that the proposed delivery was to be with breech presentation. On 28-12-92, Charulata complained of pain which indicated the forthcoming delivery and therefore, she was admitted to the hospital in the morning and was given injection for promoting labour pains. The appellant was assisted by his wife Dr. Smita Kulkarni, M.D. (Anesthetia) and Nurse Mrs. Jagdale. When the delivery pains started, Dr. Kulkarni came to be busy with a case of urgent curetting (evacuation for incomplete abortion with bleeding) of Mrs. Sathe in the adjoining operation theatre. The delivery of Charulata went of uneventful and Dr. Smita Kulkarni (wife of the appellant) gave sutures to the perineum and the sanitary towels were placed to absorb the blood. Charulata was removed to semi-private room in the same hospital. Dr. Kulkarni went on as usual for examining remaining patients and Dr. Smita Kulkarni looked after Charulata till 1.00 p.m. and left for her appointment to Anand Hospital. The nurse Mrs. Jagdale went after the duty at 12.30 noon upto 4.00 p.m. during which time another nurse Mrs. Londhe was attending Charulata.
Charulata was accompanied by her sister Mrs. Aruna Deshmukh and mother Savitribai as there was haemorrhage with abdominal trauma during the said period and more particularly after 2.30 p.m. Mrs. Londhe was informed to contact the appellant since 3.30 p.m. onwards. However, nurse Mrs. Londhe did not take any steps to contact the appellant. Only on telephone she was advised to give injection of Voveran. However, when Mrs. Jagdale nurse appeared, she found that the condition of Charulata was precarious because of serious chest pain with profused perspiration. Thereafter appellant came with Paediatrician Mr. Mankikar and local physician Dr. Khade and provided all sorts of treatment suspecting the situation to be 'Disseminated Intavascular Coagulation' (hereinafter referred as DIG). Despite their efforts for resuscitation and giving oxygen 100%, Charulata did not revive and met her clinical death at about 8.15 p.m.
4. The District Forum as indicated above, refused to accede to the defence made out by the appellant about the sudden cardiac arrest on account of massive embolism and chose to rely on the story canvassed by the complainant. Here we find that the appellant supported his say about the sudden development on account of chest pain and perspiration. The affidavits of Dr. Laxman Govindram Pherwani, Dr. A.V. Umranikar, Dr. Pritam P. Phatnani and Dr. Smita Kulkarni have been relied upon by the appellant. We held that all these affidavits present an interesting reading in this matter. First of all, we may deal with the affidavit of Lalabai Tapkir. It has been treated as a bogus affidavit by the District Forum. We feel that such a conclusion is not at all warranted. The observation of the District Fo-rum that it did not bear the signature of Mrs. Tapkir, does not at all seem to be correct. We find that the said affidavit bears the small signature of Tapkir and that the same has been notarized. In order to counter this observation, Lalabai Tapkir has filed another affidavit in which she has stated that the signature on the affidavit rejected by the District Forum is her signature although it is small in size. On the original affidavit we find that it bears the same signature as on the other affidavit. The affidavit of Lalabai Tapkir assumes importance since she has stated that she was admitted to the same hospital on 14-12-92 for removing her womb, possibly this was a family planning operation. She was on Cot No. 10 after the family planning operation, whereas Charulata was on Cot No. 11. Charulata delivered a female child. Charulata had taken food. In the afternoon she complained of pain in the chest and sister attended on her for examination of blood pressure. Sister rushed out and called the doctor, prior to that Dr. Kulkarni had examined her and found her alright in conversation with her. She was found to be replying to the question put by the doctor. She had taken tea and biscuits and Dr. Mankikar also examined her. She does not speak of profuse bleeding through uterus of Charulata. Now this affidavit has not been challenged in the cross-examination, because Lalabai Tapkir was not called for cross-examination. From the affidavit of Lalabai, one can easily gather that Charulata had no delivery problem when she was removed to Cot No. 11. There is no reference of bleeding. Unfortunately, only on the point of absence of signature, the District Forum rejected the same. On close scrutiny we find that there is a small signature of Lalabai, which has been supported in her next affidavit, wherein also we find a small signature similar to one on the affidavit dated 18-6-95.
5. We then turn to the treatment given by the doctors. The appellant doctor stated that Charulata was admitted on 28-12-92, 30 days prior to the scheduled date of her delivery, which was not abnormal, particularly in case of breech presentation. She was in labour and her cervix was dilated 3 cms and was 80% effaced. However, the appellant found that the contractions of her uterus were mild and that other vital parameters were normal. Other than labour pains, there was nothing else that was complained of by Charulata and at no time was there any question of bleeding before the birth of the child. At about 10.30 a.m., Injection Pitocin 2.5 units in 5% Dextrose Saline drip was given. This was to promote pains for early delivery, but the same had to be stopped at about 11.00 a.m. as Charulata developed severe rigors. She was immediately administered Injection Avil 2cc, intramuscularly and her response was very positive. The labour pains grew intense indicating stronger uterine contractions and Charulata Gavade was therefore shifted to the labour room at about 11.30. a.m. Charulata delivered a healthy female child, weighing about 2000 gms, at 12.00 noon. She was attended by Dr. (Mrs.) Smita Kulkami, who is equally qualified to treat the cases of delivery although she was specialised as M.D. (Anesthetist). The basic qualification M.B.B.S. is enough to qualify the doctor to attend the deliveries. The baby cried well and the delivery was uneventful. The perineal tear, which is normally expected in such deliveries, was sutured in layers and there was no bleeding from the uterus other than that normally expected. After delivery of intact placenta, she was administered Injection Methergine 0.2 mg as per the standard obstetric practice, to increase the strength, duration and frequency of uterine contractions and thus decrease post-martum Uterine bleeding. Here we may observe that in the post-mortem report on record, the uterus was found to have contracted to a normal position. There was bleeding from the uterus and that large number of clots of blood were found. The post-mortem notes read contrary to the allegation of the complainant that there was profuse bleeding from the uterus. Charulata was then shifted to another room along with her daughter, where Mrs. Lalabai Tapkir was there on Cot No. 11. Dr. (Mrs.) Smita Kulkarni again examined Charulata at about 1.00 p.m. and Charulata was found to be comfortable and did not have excessive bleeding other than normally expected. The appellant doctor examined Charulata at about 3.00 p.m. and found that her pulse and blood pressure were normal and that there was no post-martum haemorrhage. The appellant doctor then left the Hospital to go home for her lunch. We may here recall that Charulata had tea and biscuits as suggested by Mrs. Tapkir. Sister Mrs. Jagdale in her routine round found that Charulata was complaining of pain in her lower abdomen, which was not unusual and is normally found in the recently delivered women. Such pains are known as "afterpains". All the same, by way of abandon precaution, Mrs. Jagdale contacted the appellant, who advised Injection Voveran to which Charulata responded. Mrs. Jagdate also checked the blood pressure and bleeding from vagina and she removed the blood clots and reported that the bleeding from vagina has reduced. Dr. Mankikar, who also examined Charulata at about 4.45 p.m., endorsed the finding that the delivery was normal and that Charulata was quite normal. She was found to be comfortably sleeping on her bed. However, at about 6.00 p.m., Mrs. Jagdale called the appellant as Charulata had developed restlessness and was sweating profusely and was complaining of chest pain. Her pulse was found to be feeble. Appellant doctor found that Charulata had epigastric pain, but in fact it was a chest pain. Her pulse was feeble and she had suddenly gone into a state of shock. As usual, the appellant administered Injection Mephentine 15 mg intravenously to raise the blood pressure. Dr. Mankikar came to his assistance and Charulata was removed to operation theatre where the patient was placed in the 'leg-up' position to maintain adequate blood circulation to the vital parts of the body, was given oxygen and administered saline to raise her blood pressure. Dr. (Mrs.) Kulkarni also joined the duty in the resuscitation of the patient. As an Anaesthetist, she was competent in following those procedures. She immediately intubated the patient with an endotracheal tube and started artificial ventilation through Boyle's machine. Simultaneously, further, injection of Mephentine and Dopamine were given to raise the blood pressure. She was also administered Haemaccel and 5% Dextrose Saline. Charulata started to bleed from the injection sites on her arm. Doctors suspected that this was an impending development of Disseminated Intravascular Coagulopathy (D.I.C.), which in alt probability could be due to an amniotic fluid embolism, which has developed and the emergency arose. The appellant directed the husband of the complainant to secure blood from Lokmanya Blood Bank at Chinchwad, being the nearest blood bank. Meanwhile, resuscitation efforts were continued from 6.00 p.m. but unfortunately at about 6.40 p.m., the patient suddenly went into respiratory arrest from which she was successfully revived. Nevertheless, in the absence of post-partum haemorrhage, everything else was a diagnostic enigma. At about 7.15 p.m. Dr. Khade was called to help in further medical management of the patient, particularly the cardiovascular status. Dr. Khade joined the resuscitating team. He agreed that this was not a case of post-partum haemorrhage. He advised administration of Adrenaline and Aminophylline in addition to all other drugs that were being administered. The entire team was involved in combatting the sudden shock that the patient had developed. Endotracheal incubation with intermittent positive pressure respiration with 100% oxygen through Boyle's machine was administered to maintain oxygenation of the patient. The necessary injections were given. Even Injection Sodabicarb to counter acidosis and Injection Efcorlin to combat the stress situation was given and Injection Prostodine to induce uterine contractions to curtail even the physiological loss of blood was given. But in spite of all these efforts, Charulata did not survive.
6. From this case, it would be manifest that the death came about be-cause of cardiacarreste. Now, in this regard we find that the affidavit of Dr. L.G. Pherwani is illuminating. He has stated that from the post-mortem notes, the brain was weighing 1210 gms as against 1100 gms. Right lung was weighing 345 gms, as against 300-280 gms. Left lung was weighing 330 gms. as against 250-200 gms. and the heart was weighing 220 gms. as against 200-180 gms. These readings are borne out from the post-mortem notes. Now according to Dr. Pherwani the higher weight of the lungs indicate congestion. The liver is actually found congested with a weight of 1200 gms. Post mortem lividity is seen at pressure points, though it is faint. The findings in the post-mortem examination are strongly suggestive of death due to shock by amniotic fluid embolism which is a type of pulmonary embolism, a rare complication of normal delivery. The case papers shows that her respiration was irregular. There was pulmonary congestion in the lungs. She brought out frothy fluid through the endotracheal tube, rendering difficulty in ventilating the patient, bleeding from puncture sites indicate possible onset of Disseminated Intravascular Coagulation (D.I.C.) and there was no response to the very vigorous treatment of shock. Dr. Pherwani felt that all these symptoms clearly suggested massive pulmonary embolism as the cause of death. Dr. Phatnani who is known in the Forensic medicines, discounted the allegation that the uterus of the deceased was not at all contracted but was flabby containing large clots of blood. The post mortem notes indicated that uterus was contracted, cavity contains blood clots, cervix lacerated, but measurement of laceration has not been mentioned. Regarding conclusion about the post partum haemorrhage, it is stated that the vital organs should have been sent to histopathological examination and not mere clinical examination. The said examination could have revealed the correct cause of death. The finding of the District Forum that absence of details of actual delivery leads to infer rupture of either uterine or abruption of placenta leading to continuous haemorrhage forcing the deceased to land into the grey area of clinical death, was not at all warranted because there was no indication about the abruption of placenta. It was a case of sudden development of shock along with marginal laceration of the cervix. There was every possibility of the patient's death occurring due to amniotic fluid embolism. The medical literature also shows that the marked pulmonary oedema and congestion are usually evident and there is frequently significant acute cor polynomials. In addition, there may be marked congestion or other visceral organs, most notably the liver. On-set of symptoms of pulmonary embolism may start within 10 minutes or even may develop 32 hours post partum. The patients may remain normal and with the onset of symptomology the time interval may vary from 10 minutes to 32 hours. Since the doctors have gone through the postmortem notes they have unanimously suggested that this was not a case of post partum haemorrhage, the uterus has contracted and this was an indication of slow down of haemorrhage. On the other hand, we find in the statement of sister of the deceased that when she saw the patient, she found needles and tubes inserted in the mouth and body of the deceased. This was, therefore, supporting of the case of Indotracheal tube being put for dripping saline being given, which are consistent with the treatment of D.I.C. From the aforesaid documents on record, we are unable to subscribe to the observations of the District Forum. The appellant and his wife also supported the story of the pulmonary embolism, so also the Nurse Jagdale. Although this evidence is a bias evidence, the evidence of Dr. Pherwani and Dr. Phatnani suggest the death on account of pulmonary embolism. Dr. Umranikar has also suggested that there was nothing wrong in the appellant rushing to the aid of Mrs. Sathe, whose life was in peril. We do not see any deficiency in the treatment. The patient was adequately attended to. We, therefore, pass the following order:
ORDER "The Appeal is allowed. The order of the District Forum is set aside. The original complaint is dismissed. The amount if any, deposited by the appellant in the Redressal Forum should be refunded to the appellant."
7. Appeal allowed.