National Consumer Disputes Redressal
Gopi Ram Goyal & Ors. vs National Heart Institute & Ors. on 28 February, 2001
ORDER
MR. B.K. Taimini
1. This complaint has been filed by the widow and legal heirs of the deceased Shri. Ram Pratap Goyal alleging medical negligence on the part of Opposite Party Nos. 1, 2 & 3. Shri Goyal had died at Delhi on 1.7.1991 following open heart surgery conducted by Dr. Sharma, Opposite Party No.2 in the national Heart Institute - Opposite Party No.1. The blood was supplied by Opposite Party No. 3. The brief facts of the case are that the deceased, Mr. R. P. Goyal was suffering from heart trouble for which he was brought for check up to the National Heart Institute on 20.12.1990, where, on the advice of Dr. S. Padmavathi, Chief Medical Adviser of the Opposite Party No.1, angiography test was carried out on 24.12.1990. Dr. Padmavati advised the Complainant for open heart surgery which was carried out by Opposite Party No.2 on 17.6.1991. The surgery which took about five hours was successful and the deceased patient was brought to the recovery room at about 2.45 PM on 17.6.1991. As per records, the condition of the deceased patient was normal with regard to all known parameters like temperature, haemoglobin, passing of urine. In fact the patient had woken up at 3.25 PM on 17.6.1991 and soon after the deceased patient was given compose injection to make him sleep at 4.30 PM. The second dose of compose was given at about 6.30 PM. Till about 7.00 PM, the drainage was normal, after which, around 8.00 PM, it started becoming excessive. The record shows that along with excessive drainage, the pulse rate had become steeply high. At about 7.00 PM on 17.6.1991, the blood pressure which was at about 120/90 had dropped to 60 at about 8.00 PM and remained low. Three symptoms were noticed. Firstly, the pulse rate going slow, secondly, dropping of blood pressure and thirdly, excessive drainage. At about 8.00 PM, the urine out put dropped to 30 cc/hr which in at a low side. With a view to as certain the cause of drainage from the chest, the patient was against taken for re-exploration, no surgical cause could be detected. The patient was brought back after re-exploration, after that there was no drainage. The opposite Party No. 2 was there till about 1.00 AM of 18.6.1991. At about 4.00 AM on 18.6.1991, the Opposite Party No.2, on emergency call, came back to attend the patient wherein he was told by the attending Dr. A.K. Dass that the patient had had a cardiac arrest at about 3.25 AM and that the patient had already been revived by the attending Doctor, Dr. A.K. Das. The patient had a cardiac arrest for about 4-5 minutes. The Opposite Party No. 2 went through the charts to ascertain the incriminating cause for the cardiac arrest. According to the Complainants, the deceseased - Shri Goyal had remained unconcious from 17.6.91 to 1.7.1991 and ultimately breathed his last at 9.20 AM on 1.7.1991. The Complainants also state that due to unconsciousness, he developed temperature and juandice. the Opposite Party - Hospital issued the death certificate in which it was mentioned that the cause of death was Post CABG Severe Transfusion Reaction, CVA following cardiac arrest, Septicaemia and multi organ failure. It is alleged by the Complaianants that the death of Shri Goyal was due to negligent acts of the Opposite Parties for the following reasons:-
1. That without any test the blood transfusion was given to the patient by OP no.
2. That there was no provision for Blood bank in the hospital which is an essential item for operation of heart surgery although this facility is available in other private hospitals like Escorts, Batra.
3. That the re-opening of the operation without any cause is enough to establish the negligence.
4. There was infection in respiratory pipe.
5. There was septiceamia.
6. That either the transmitted blood was not of good quality or the blood group of the patient was different than that the blood transmitted.
7. That the patient remained unconscious from the time of operation till date.
8. That at the time of cardiac arrest, the OP No. 2 was not present in the Hospital and that he had taken more than 45 minutes to attend to the patient. During the period unattended, the circulation of blood was stopped and blood clotting taken place which had attributed to remain unconscious till death. This was due to the negligency of OP NOs. 1 and 2.
9. That the OP No.2 had also operated three heart patients namely Firangi Singh on 30.4.91, R.N. Mehra on 22.5.91 and Mr. Vishwanathan on 29.6.91. They had also suffered from the same problem and ultimately they died.
10. That a request was made by the complainants to OP No. 2 that you may kindly obtain second opinion. Then he told that their hospital administrative rules do not allow us.
11. That the complainants are entitled to get the compensation amounting to Rs. 10 lacs and actual expenses incurred for the negligent act of the opposite parties resulting in the death of Ram Pratap Goyal who was father of the Complainant Nos. 1 to 4 and husband of Complainant No.5.
2. For the acts of negligence on the part of Opposite parties, the Complainant asked for compensation of Rs. 11,33,500/- including actual expenses incurred on the treatment of the deceased at Rs. 1,33,500/- and a compensation of Rs. 10 lakhs.
3. A Joint reply was filed by Opp.Party Nos. 1 & 2 in which they state that the patient had a long standing ailment since 1984-85 and chronic obstructive air way disease and these factors made him a high risk patient. The angiography test was done on 24.12.90 which revealed Severe Coronary Artery disease involving two major arteries of the heart (Left Anterior descending and Circumflex Arteries). It also revealed left ventricular dysfunction in the form of apical akinesia (Ejection fraction 40%). According to them the position was explained to the next of kin of the deceased. They also stated that the blood supplied by the OP No. 3 is duly certified and tested against aids, Hepatitis and also cross-matched against the patient's blood and specific group. According to them on re-exploration, it was found that bleeding had ocurred from the raw edges of the breast bonos. They also stated that due to transfusion of 8th unit of blood, red rashes appeared on the face and chest of the patient; antihistaminic like AVIL and EFCORLINE were given to avoid re-action. The patient was also throwing ventricular ectopics after the operation and required Xylocard which was anti arrythmic infusion to control the octopics. The OP No. 2 had left for his residence at about 1.15 AM on 18.6.1991 and at about 3.25 AM cardiac arrest occured and Dr. A.K. Das the attending surgeon, revived the patient. According to them, on account of prolonged illness, as already explained above and recumbency particulary keeping in view the existing chronic obstructive airway disease, the patient developed infection and started having fever and jaundice; the patient was given specific antibiotics and round the clock cover by way of medical attendance by qualified and trained nurses and surgeons in the post operative room and at no time during his hospitalisation, the patient was unattended. The OP Nos. 1 & 2 had denied that the patient remained unconscious from 17.6.1991 ti 1.7.1991. According to them, the patient had regained conciousness on 17.6.1991 and he was given sedation to make him confortable. The patient was subsequently seen by Dr. S. Janki and Dr. Col. M.L. Suri, leading Neurologists. According to them, the blood which was transfused to late Ram Pratap Goyal was tested and cross-matched.
4. According to the OP Nos. 1 & 2, as far as the allegation No.1 is concerned, no fresh tests than those done in the Laboratory are undertaken as decisions were taken as the blood units are sealed packs and opened only when used for the patient.
5. With regard to allegation No.2, it is only a suggestion and it cannot be attributed as a negligence.
6. With regard to allegation No. 3, the re-opening of the operation was not without any cause i.e. it was resorted to rule out any surgical cause for bleeding and this alone is enough to establish and bonafides for re-exploration. This allegation is without any merit as it is left to the surgeon to ascertain the cause of bleeding and for that this is a normal practice to re-explore to rule out the cause as any surgical lapse.
7. According to them, allegation Nos. 4 & 5 are also without any merit. The infection and septiceamia occured due to prolonged illness and recumbency causing catabolic response of the body and it occured in spite of full antibiotic cover, barrier nursing and precautions, The patient was under intensive care throughout.
8. With regard to allegation No. 6, OP Nos.1 & 2 state that the blood was from an established blood bank run by a qualified pathologist and the quality and genuineness of the test is known to be reliable and authentic. The blood group of the patient and that of the transfused blood was cross-matched and checked.
9. As far as allegation No.7 is concerned, it is not correct that the patient remained unconscious from the time of operation till death. The patient gained consciousness at 3.45 PM on 17.6.91. Even on 18th 19th and subsequently on 26th June, 1991, as observed by Dr. Col. M.L. Suri, a Neurologist, the patient was found improving and he was responding to commands. The patient was also examined by a well known Neurologist Dr. S. Janki.
10. Rebutting allegation No. 8, the OP Nos 1 & 2 state that it is not always possible for the surgeon to be present all the time with the patient. The OP NO. 2 had left for his residence at about 1.15 AM on 18.6.1991 after assuring himself that the condition of the patient is stable. He was still under the care of Dr. A.K. Das, a fully qualified cardiothoracic surgeon and it was he who revived the patient (for 4-5 minutes) after the cardiac arrest.
11. Rebutting allegation No.9, OP No.2 states that this has no correlation with the facts.
12. Rebutting allegation No. 10, OP No.2 had specifically denied that any such request was made by the Complainants to obtain second opinion, hence had no occasion to state that the hospital rules do not allow for second opinion.
13. Rebutting allegation No.11, OP Nos. 1 & 2 state that there has been no negligence whatsoever on their part.
14. On the contrary, the record of the operation and the post operation period will show that they have provided best of services to the deceased by qualified surgeons and competent and qualified nursing staff. In spite of the services rendered, the patient died on account of facts mentioned in the Death Certificate and not on account of any negligence on the part of the OP Nos. 1 & 2.
15. In reply to the complaint filed by the Complainant, OP No. 3 replied that it carried out two basic tests; one to match the blood group and second to match the compatiability of the blood to be supplied with that of the receipent's sample. This was done in this case. He further states that it is well established that if the blood supplied by the Blood Bank is found, during transfusion, to be incompatible, the reciepient reacts in a clearly identifiable manner and the reaction may include shivering, an increase in the pulse rate, cold sweat, difficulty in breathing and a fall in blood pressure. Such reaction during transfusion in almost all cases is detected within 20-30 minutes of the transfusion. According to established medical practice, as soon as such reaction is detected, the transfusion blood sample of the reciepient is immediately sent to the blood bank from where the blood was received for analysis. OP No. 3 had supplied 8 units of blood on 16.6.1991, 4 units on 17.6.1991 and further 2 units on 18.6.1991 against the request received from National Heart Institute for purposes of giving it to the patient. In his reply, the OP No.3 also states that OP Nos. 1 & have incorrectly shown the case of death as "severe transfusion reaction" in order to shift the blame for the death of the deceased.
16. In a rejoinder filed by the Complainants, they have further stated that angiography test remains valid for three months only and after that new test has to be carried out and on the basis of that now test, the doctor has to proceed further, whereas the present surgery was based on angiography test done on 24.12.90 and the operation was done on the patient on 17.6.1991 i.e. after more than six months inferring this to be an act of negligence on the part of the Opposite Party Nos. 1 & 2. The second angiography test was necessary. They also further allege that no risk of the surgery was explained to anyone attending on the patient. They further allege that OP No. 3 did not carry the necessary tests on the blood sold as per the norms prescribed in Medical Laboratory Technology. They also allege that operating Surgeon, Dr. Sharma had told them that the blood which was given to the patient reacted but they did not know anything about such a reaction. As a result of the reaction, the prescribed procedure as laid down in the Medical Laboratory Technology was not followed which is an act of gross negligence on the part of the OP No.2 and according to them this was the cause leading the death of Shri. Goyal.
17. The Complainant led the evidence of 9 witnesses.
CW 1: The Complainant's 1st Witness is Dr. A.K. Saraya who was working as professor & Head of the Department of Haematology, AIIMS. On a question being asked as the whenever there is a disorder, investigation in a must or not? The Witness stated that this is a discipline which is practices on patients but its diagnosis is always made in the laboratory. He further stated that every disorder need to be investigated. On a specific reference, Dr. Saraya, after seeing the profile of the deceased and after going through states categorically that "it is a very mild Haemolytic reaction, if at all it is". Asked specifically about the related parameters like urine output in this, the Witness stated that he has no practical experience since he is a laboratory man and he will not be able to comment on them.
CW 2 : The Complainant's 2nd Witness is Dr. Ms. Ambika Nanu who is working as Addl.Professor at the Blood Bank, AIIMS. She states that when they get a report of transfusion reaction from a clinician then they tell the blood bank the symptoms and they also send back and blood bag and the transfusion set. We also ask them to send us sample of the patient's blood after the transfusion. The procedure followed by Blood Banks in such cases is a standard one as per guidelines issued by the Directorate General of Health Services on this subject. According to her, the common symptoms of blood reaction which is known as Febrile reaction i.e. there is slight rise in temperature. She also states that there might be a minor and major reaction of blood transfusion. She also states that there is no connection between these two reactions. On a specific question being asked whether blood transfusion reaction can cause bleeding of wound or not, she stated "Yes". She also stated that there can be early as well as delayed reaction. She categorically stated that in case of intravascular Haemolysis, which is in the instant case, it is usually an immediate reaction. Upon being asked as to what kind of symptoms of blood transfusion the patient manifests, she stated that he may complain of feeling of a sense of apprehension or anxiety, he may complain of chest pain, back pain, pain on the infusion site, shock-red coloured urine and rigor. On being asked, can blood transfusion reaction be called speticimea? Her answer was "If it is an infected unit". She states that intravascular transfusion can cause death. On being asked whether Febrile reaction is commonly known as allergic reaction. Her answer was "No", it is a different one. Allergic reaction is an urticarial reaction. It is most likely due to anti-bodies to plasma proteins. Urticarial is most common one. It can be the only reaction or it can be only part of most severe reaction. Therefore what it recommended is to stop the transfusion, get the preliminary test done and then give anti-histamine and continue the transfusion. It is entirely upto the clinician whether to send the blood to the blood bank or not and there is no hard and fast rule in medicine. She states that if there is a severe intravascular transfusion then kidneys will be affected affecting the patient's urine output and his bilurubin count will go up after 8 hours to about 7-8 mg, but will definetly be more than 3 mg. She also states that in such a situation, the patient has to be managed clinically. She concedes that the tests which were carried on receipt of blood after reaction, is not included in the test because there is as yet no test, which we do for detecting an allergy.
CW 3 : Complainant's third witness is Dr. M.L. Gupta. Dr. Gupta is a Director of the Blood Bank of the Indian Red Cross Society, New Delhi. He states that all blood transfusion reactions need to be investigated but there is no written regulation as to how the transfusion reactions are to be investigated. There are guidelines laid down by Ministry of Health about how the blood banking is to be done but there are no documents whatsoever about the methodology to be followed in carrying out such investigations. Upon being asked a question "should all the reactions be investigated or not?" The witness said "Yes", but there is no such authority who should investigate these reactions, either nominated by the Government or any body. He goes on to say that each large hospital should have its own blood bank. If we divide the transfusion reaction, they are either of non-haemolytic nature or of haemolytic nature. Haemolytic nature are very serious and then we really mean investigation. The non-haemolytic reactions are usually treated symptomatically with the transfusion facility and the immediate first principle is to stop the transfusion, discard the blood and do not give any further transfusions and change the set also. The non-haemolytic means which do not destroy the cells within the body of the patient. These are the fever type of or mostly the allergic type of reaction is so severe that they will come to know (clinicians) about it immediately. The Witness states that in the case of severe reaction, the patient may not tolerate even 5 cc of blood. He goes on to say that there is no definite rule that after 5 minutes clock will start running. It all depends on the severity of the symptoms, and the severity of the reaction. According to him, the symptoms of blood transfusion reaction are pain in the chest, burning on the site of the transfusion, back severe lumber pain, fall in blood pressure and urine output and rigour. What is required to be done in such cases is that the Clinician shall stop blood for some time and give an injection of Avil or Decardon and re-start the same and further states that rigour cannot be said to be a major symptom. He further states that rigour will come into the non-haemolytic reactions where as the haemolytic reaction would generally fall in a category which is severe but the two are not usually associated. This Witness will not bother about it unless accompanied by two crucial and critical symptoms i.e. fall of blood pressure and decrease in the urinary outflow. On a specific question whether cerebrovascular reaction is a result of severe transfusion reaction, he says "No" and reiterated that blood transfusion can cause speticeamia only if the blood is infected. On cross-examination, he was asked whether a cardiac arrest can be attributed to allergies like rashes appearing on the face or chest of the patient, he says "I don't think so". He also admits that in practice, nobody reports about these reactions.
CW 4 : The Complainant's 4th Witness is Dr. (Mrs) Sashi Kiran Anand, Dr. (Mrs.) Anand is incharge of Department of Pathology, NDMC Hospital, Moti Bagh, now called Charak Hospital. She explains that whenever there is haemolytic reaction as a result of blood transfusion, the red blood cells break up. She also states that all the blood reactions need not be severe but there can be mild as well and as a result of blood reaction, certain clinical signs like cholls, fever, haemoglobuma, shock, hypotension, as reaction is noticed, we stop the blood. She concedes that whenever there is blood transfusion reaction, investigation is a must and it is to be intimated to the blood bank. She also states that when a person has undergone a bye-pass surgery, the patient's blood is hyperanised for some time. The bleeding tendency in much more and it normally increases and in any case, when you give 4-5 bottle of blood, this bleeding tendency increases and it may be due to platelets because when we give blood from outside, it is not exactly a fresh blood so the bleeding tendency also normally increases to some extent. The bleeding in said to be blood reaction because of the blood you have given to the body. On cross-examination, she admits that she has never seen a bye-pass surgery but just spoken to friends who are doing it.
CW 5 : The Complainant's 5th witness is Dr. Santosh Sindhwani. Dr. Sindhwani is incharge of Blood Bank, Batra Hospital. He states that the blood reaction due to blood transfusion may be mild or major or immediate or delayed. He also states that if there is any reaction, minor febrile reaction or little rigour or chills, they are instructed to stop immediately the blood transfusion, inform us and send the blood back to the blood bank. If the reaction is minor, i.e. just a low fever or a low shivering then the blood is stopped and the patient is given antihistaminics like Avil or whatever the Doctor says. He also states that if blood transfusion is detected early, death of a patient can be avoided; but if there is severe haemolytic because of incompatible transfusion then patient sometimes may or may not be saved. On a specific question - Can haemolysis occur after 10 or 12 days of the heart surgery? His answer was that he cannot say about it. He also stated that it is very uncommon, meaning thereby that severe reaction is almost immediate. He further states that Urticaria may be severe or it may be mild depending upon the intensity. If you get little it will be mild and if you get generalised, it will be severe.
CW 6 is Complainant No.1 Gopi Ram Goyal, Son of the deceased. In cross-examination he admits that in the affidavit he states that cross-matching of the blood group was also conducted by OP No.3 and only after this process, OP NO.3 supplied blood to the Complainant and subsequently in the Rejoinder filed by the Complainants, the Witness states that no such test was carried out. On being asked about the contradictory averments, the Witness states that both are correct. In fact, contradictions are writ large in his whole cross-examination. For example, in the Rejoinder, he states that angiography in valid only for three months. When asked "On what basis he says so?. The answer is "I cannot say". In his Rejoinder, which is subsequently affirmed, states that at 5.00 AM on 18.6.1991, Dr. Sharma, who performed the main surgery, told the witness in explicit terms that the blood which was given to the patient reacted but they could not know of such reaction. On being asked in cross-examination as to why this fact was not explained in the complaint, he stated that he cannot give any explanation as to why these facts were not given in the complaint. There are host of facts in the rejoinder but not mentioned in the complaint; he could no give any satisfactory answer for these discrepancies and he was throughout evasive.
CW 7 : The Complainant's 7th Witnesses is Mr. Subhash Chandra Goel - Complainant No.2, states that he has not read the complaint or the rejoinder as he is not able to read English. In his cross-examination, the states that he was not explained about the risk in the surgery nor was he told to arrange for the blood.
CW No. 8 : Complainant's Witness No. 8, Mr. Bajrang Das - Complainant No. 4. He says that he has signed the consent from on 16.6.1991 for carrying out the operation. Neither Dr. Das nor Dr. Sharma explained the risks in carrying the operation.
CW No. 9 : The Complainant's Witness No. 9 is Dr. Mukund Lal Sharma, a Cardio-thorasic Surgeon who had prepared the Death Certificate. He admits that the Death Certificate outlining the cause of death was filled in by him. He stated his turn of duties from 21.6.1991, as before that date, he was not available in the hospital being on leave. Since the patient died during his duty hours, the witness had to fill in the Death Certificate and this is as per the records. He clearly states that due to severe transfusion reaction the patient had some rashes over the body. On a specific question asked whether his observation is based on the chart which shown only the rashes appearing on the face or the chest. The answer categorically was "Yes". He adds that it was the Nuerologist who also stated the same. (He was referring to the notes of the leading Nuerologist Dr. Janki who examined the patient on 28.6.1991 wherein she mentions "blood reaction"). On being asked specifically as to "When you wrote this severe transfusion reaction and does it imply that the patient had suffered some Haemolytic reaction? The answer was "No, Haemolytic reaction is entirely a different entity. It can be severe anaphylaxis, it could be severe haemolytic reaction, it could be sever even with glucose. We write severe reaction - severe does not mean that, Haemolytic is a different entity". On a specific question as to whether transfusion can cause cardiac arrest; and is there any relationship? The answer was "No relationship, Sir. It is independent". On a specific question being asked by Member of the Commission, "What we find is four different causes given for the cause of death - severe transfusion, cardiac arrest, speticimea and multi-organ failure. Now is it due to the affect of all these or due to failure of one? The answer to this is that the National Heart Institute being an academic institute, this will be chronology of morbid events which we write ultimately leading to death. We cannot ignore anyone since septicemea is partly responsible and septicemea is responsible for multi-organ failure. On a specific question being asked by the Bench, whether he was there all the time, the answer was "I was not there at that time". The Bench further asked whether it was of more in the realm of speculation? The answer was "Yes".
18. On behalf of the Opposite Parties, 5 Witnesses wee examined.
19. Opposite Party No.1 - Dr. M.L. Sharma was the operating surgeon who after giving brief history of the case stated that the patient developed chest pain on 30.11.1990 while resting. This pain had recurred on 2.12.1990 and he had similar pain on and off since 1984. This time the patient had severe pain and he was diagnosed as a case of unstable angina and was advised for coronary angiography along with other tests which showed enough evidence of coronary artery disease. Then an 'echo' had been done on 14.3.1991 and that had shown serious cardiac problem. When the cardio-cath (angiography) was done on 24.12.1990, which showed that the two coronary arteries, the left anterior descending as well as the left circumflex were both significantly diseased.
20. After due consideration, it was decided to suggest surgery which was carried out on 17.6.1990. The surgery was over by by 2.45 and he was brought back to the intensive care room at 2.45 PM. The blood pressure was normal - around 120-130 and pulse rate was normal around 85-86. There was nom excessive drainage and he was passing lot of urine. On being asked whether in the recovery room - did he notice any reaction as a result of blood which might have been transfused earlier? The answer was he did not notice any untoward reaction to the drugs or the blood until he was there, which is generally a couple of hours after the patient was brought back to the room. He did not have any evidence of any untoward reaction and the deceased was maintaining stable haemo-dynamics. The drainage started becoming excessive after 7 PM. Along with excessive drainage, pulse rate also went up. It was decided by the surgeon to look into upon the cause of excessive drainage, which is normally done through re-exploration, meaning thereby this - the patient's chest in re-opened. On re-exploration, no surgical cause was noticed and the patient was brought back. There was no bleeding for some time. The Witness justified re-exploration on the ground that the patient is given haperine during the operation which keeps the blood in a thin state. But this appeared to be a case of haperine rebounds since the bleeding still persisted hence the witness was justified in taking the patient for re-exploration. The patient was brought back at 11.30 PM on 17.6.1991. The blood pressure remained 95, 100 and pulse rate was 138, 120 and there was no drainage for the first few hours and slight amount of drainage started after 4.00 AM. The witness left at about 1.15 AM on 18.6.1991 and he was informed later that the patient had a cardiac arrest and that the patient had been revived by the attending doctor, Dr. A.K. Das, who himself is a Cardiac Surgeon. On a perusal of the charts, "I found everying normal". Blood pressure is normal, the amount of urine s normal. After going through the chart and records, the witness states that the patient was reported to have rashes on the upper part of the body i.e. on the chest as well as on the face which appeared after the start of blood transfusion. So the attending Doctor told him (the Witness) that they stopped the blood and started looking at the possible cause of red rashes. According to the Witness, lot of time, medicines cause red rashes - Protomin and Morphine. After perusal of the record the witness states that the reaction occured when the 7th unit of blood started i.e. approx. at 7.00 PM and he goes on to say that the patient was normal and continued to show normal symptoms as well as the blood pressure, other parameters like urine output and bilurubin on the 18th, 19th and 21st of June, 1991 after revival of cardiac arrest. On the morning of 19th June, 1991, the patient started passing Haemolised urine, hence 100 cc's of MANITOL was given and urine became clear. His bilurubin is recorded at 3 gm. The attending Doctor has also recorded other evidence of Haemolysis goint on. Witness stated that little bit of Haemolysis is bound to occur in the body after massive blood transfusion on account of increased fragility of blood in the storage. It was on the night of 23.6.1991 that the deceased had a temperature of 100 degrees. This was the 6th post-operative day. On 24.12.1991, temperature again was 100 degrees and bilurubin count had come down to .8 after which he had been given a metacin. The fever did not come down in spite of wide antiseptic cover. On 25.6.1991, the culture was done from the wind pipe. The report dated 26.6.1991 shows it to be drug resistant organisms. The patient got into a stage of septicemia leading to multiple organ failure and his unfortunate death. All other parameters were normal on 26th, 27th and 28th except the temperature. Even on 29th June the haemodynamics and the amount of urine were normal, however the temperature went up to 103 degrees and the blood pressure started going up to 90 or 80. The blood pressure had suddenly dropped down on 30.6.1990. The blood pressure started falling and the kidneys failed on account of which the urine output was very meagre. In cross-examination, he admits that the cerebrovascular accident is due to cardiac arrest of the deceased. Dr. Das, the other attending surgeon on the deceased also told the witness that the patient had developed rashes and this was documentated and according to the witness, the rashes are very mild and which are non-specific in nature. The witness states that he could not disagree or have any other view unless there was any further evidence on this subject. If there is a haemolytic reaction or he knew the kidneys had failed on the post-operative day, it does not cost anything to the hospital to send it for cross-checking. he also states that he was told that, that particular unit which resulted in rashes was changed.
21. The witness further goes on to say that the patient had had a massive transfusion, in all he had 18 bottles of this blood. Little bit of haemolytic reaction is bound to occur in the body and that in a normal practice. We have been churning the blood for nearly 2 hours during the re-opening heart surgery, this again causes little bit of haemolytic reaction. According to the Witness, haemolytic reaction could have occured after massive transfusion even at a delayed stage but it needs to be seen in perspective as well in the company of all other parameters which were stable and under control in the instant case. The witness says that severe transfusion reaction was written by the concerned Doctor at the time of death and that too based on the record.
22. The Opposite Parties' 2nd Witness was Dr. Rajan Ghadiok who is an Anaesthesist. He states that the patient was given Haparine to prevent the blood coagulation which was neutralised with a drug called protamine. Protamine Sulphate does have side effects, it could be in the form of a mild rash, severe rash - it can be in the form of hypotnesion i.e. drop in blood pressure and in a very severe reaction can even cause cardiac stand-still.
23. The 3rd Witness is Col. Dr. M.L. Suri who is a Neurologist. He admits that he has written after examining the patient on 18.6.91. He had written that the patient had anoxic encephalopathy i.e. damage to the brain because of insufficient or no oxygen reaching the brain. In his cross-examination, the witness mays that on examination, he had found that the deceased had a cardiac arrest at 4.00 in the morning and following that there is a dys-function in the brain which was the result of the cardiac arrest.
24. Opposite Parties' Witness No. 4 in Dr. Maj. Gen. M. Bose who is incharge of the Blood Bank and Haematology Laboratory of the Escorts Heart Institute, New Delhi. When asked "what signs would he look for severe haemolytic reaction? He said that he would look for two things - one total bilirubin concentration in the serum and secondly, special division of that into conjugated and unconjugated bilirubin. Explaining further he stated that haemolytic reaction means destruction of red cells in the blood, they break up due to antigen antibody reaction. When asked "when the unconjugated is more than the conjugated, then is there severe transfusion?, the answer was "Not severe. Haemolytic reaction can be mild and it can be severe". On a specific question being asked can severe haemolytic reaction cause cardiac arrest, the answer is "I don't think". On being asked can Haemolytic reaction cause cardiac arrest. He says "the book says that there may be some spasm of coronary artery there may be just pain, spasm of giddiness with difficulty to breathe. He goes on to say that if there is only articaria, who do not take any cognizance of that, higher bilirubin can be due to 101 causes". On a specific question being asked by the counsel for the complainant, the death certificate issued by the national heart institute and the registrar of the birth and death - all say that it is because of the severe transfusion. The witness says has it been investigated? The symptoms of severe reaction are sudden fall in blood pressure chest pain, kidney failure, reduced quantity of urine, red colour in urine. He reiterated, on cross-examination by Counsel for the Opposite Party No.3, "if there was a severe transfusion that it will result in urinary failure and in the case of severe reaction, the bilirubin will definetly go up.
25. The Opposite Parties' Witness No. 5 is Dr. Arvind Lal who states that they had supplied 14 bottles of blood on request by the National Heart Institute - OP NO.1 and they are duly checked as per the guidelines and practice before they are supplied to the organisation from where the request has been recieved. Along with 14 bottles supplied by the hospital from professional sources, 2 bottles were from relatives i.e.l from non-professional source. He admits that when the second requisition came, there was no intimation about any blood reaction - whether minor or otherwise. According to the witness, the last report which they have got about the minor or severe blood reaction was about 10 years ago. On being asked, if there is some urticaria, some rashes or some rise in temperature, will they still refer to the blood bank? The answer was only if they think that it is severe transfusion reaction.
26. He further station that the biggest problem is Anurea which means complete stoppage of the urine and the treatment for that is only haemodialysis straightaway. In this case, the urine output has been on an average 2685 ml /24 hrs; he has never taken out less than 1600 ml of urine, 1.6 litres of shows that the patient may have anteing but he did not have anuria s a result of server blook transfusion. His average haemoglobin is still 11.9. He further states that severe reaction because of hypersensitivity reaction which responds to drugs like avil and efcorlin and then there is Protamin zinc Sulphate which is also known t o cause reaction through out the world. He states that haemolytic blood transfusion reaction can be one of them but there is no evidence to this. He further concedes that if there is severe transfusion, the blood has to be stopped no further transfusion till they get the OK from the blood bank and on a query from the Bench, the witness reiterates that in case of severe blood transfusion, the haemoglobin falls. He also stated that in the case of severe transfusion reaction along with kidney shut down, other symptom is break-down of RBCs- Haemolysis - the patient will keep passing red of brow coloured urine, which is not goint to stop by conventional therapy.
27. The counsel for the complainant argued that the entire case revolves on the severe blood severe blood transfusion reaction which caused death. According to the complainant, the moment blood reaction was found the transfusion of blood should have been immediately stopped and steps taken as per rule and guidelines published by the Government regarding blood transfusion reaction. The counsel for the complainant also relied on the fact that the Opposite Party No. 2 has stated on oath in his affidavit "that the patient unfortunately died for reasons as already stated in the certification of death" and the certificate clearly states along with other reasons 'severe blood transfusion' as the cause of death. The counsel relied on the judgment of the Delhi Court in AIR 1984 Delhi 20 - M/s. Rudnap Export Import Vs. Eastern Associates Co. & Ors. which laid down that "..... documents have been filed by the plaintiff and they are an important link in the correspondence between the parties. These documents can be looked into and the defendants are entitled to take advantage of these letters ..... that a letter filed by a party may be looked into without any further proof at the instance of the Opposite Party". According to the Complainant the pleading of the Opp.Party No.2 that 'reaction was not severe, only somebody has mentioned'. is not enough as the death certification clearly states that the cause of death is severe blood transfusion reaction. The Complainant also relied upon the decision of the Supreme Court in AIR 1987 Sc 2179 in which it was held that "the pleadings of the parties form the foundation of their case and it is not open to them to give up the case set out in the pleadings and propound a new and different case". The Complainant also relied upon the judgement of the Hon'ble Supreme Court in Air 1974 SC 471 Nagain Das Ram Das Vs. Dalpatram Iccharam Alias Brijram & Ors. wherein it was held "admissions, if true and clear, are by far the best proof of the facts admitted and they by themselves can be made the foundation of the rights of the parties". The Compliant also relied upon a judgment of the Supreme Court in AIR 1951 SC 177 Srinivas Ram Vs. Mahabir Prasad & Ors." A demand of the plaintiff based on the defendants own plea cannot be possibly regarded with surprise by the latter and no question of adducing evidence on these facts would arise when they were expressly admitted by the defendant in his pleadings. In such circumstances, no injustice can possibly result to the defendant, it may not be proper to drive the plaintiff to a separate suit". According to the counsel for the Compliant it has been admitted by Dr. Sinha who was one of the attending surgeons on the deceased that in the morning of 19.6.1991 he (deceased) started passing haemolysed urine. Doctor gave 100 ml. Manitol at 7.30 AM. Subsequently, the urine became clear. These notes proves that there was evidence of haemolysis i.e. severe transfusion reaction. The counsel for the Complainant also relied upon the judgment of the Supreme Court in M/s. spring Meadows Hospital that very often in a claim for compensation arising out the medical negligence a plea is taken that it is a case of bona fide mistake which under certain circumstances may be excusable but a mistake which would tantamount to negligence cannot be pardoned. In the former case a court can accept: the ordinary human fallibility which precludes the liability while in the latter the conduct of the defendant has gone beyond bounds of what is expected of the reasonable skill of a competent doctor". According to them after noticing severe blood reaction, admittedly no steps were taken for treating the same. According to the Complainant, the cause of cardiac arrest was also lack of supply of oxygen on account of breakage of red blood cells as a result of haemolysis. According to the Complainant, they were not explained the rise involved in the surgery. This is a clear case of negligence on the part of the Opposite Party who after noticing blood transfusion reaction, did not take proper care which resulted in cardiac arrest, septicemia, jaundice and multiple organ failure resulting the death of the deceased.
28. On the other hand, it was argued by the counsel for the Opposite Party No. 2 that the patient came in a very bad shape to Opposite Party No.2 and he was correctly diagnosed. The surgery was successful and he was brought back on 17th June, 1991 in a stable condition where he regained consciousness upon which he was given sedative to let him rest completely. The pulse was normal and his urine discharge was normal. The only visible symptom, if that can be called a symptom was rash on the chest and face of the deceased upon which immediately the attending doctor stopped blood transfusion and administered anti histamine injections. Once the bleeding did not stop he was further taken for re-exploration from where he (deceased) came back again with normal parameters and there was no bleeding for about 4 hours. According to the Opposite Party No.2 he was informed of the cardiac arrest at about 3.25 AM whereupon, he rushed to the hospital, but by that time the attending doctor, who was a qualified doctor, had already revived the patient. There has been no other symptom visible or otherwise of any blood transfusion reaction except the rashes that occured before the re-exploration on the evening of 17th June, 1991, after which more blood was transfused but nothing adverse were noticed on the body or otherwise of the deceased. The only exception being that on the 19th the attending doctor noticed red coloured urine upon which 100 ml. Manitol was given. Subsequently, urine became clear and this is the sole episode in which haemolysed urine was passed by the patient. The Opposite Party No.2 has also relied upon the evidence of Dr. Bose Opposite Parties Witness No.4. He has stated in his evidence that concentration of unconjugated billirubin is more than conjugated in a haemolytical reaction. But in the instant case the billirubin count after 48 hours was 3 of which conjugated was 1.6 which is more than unconjugated and therefore this most critical factor did not suggest any haemolytic reaction. According to Dr. Saraya, Complainants' Witness No. 1 after going through the records in detail, stated that it can be called mild haemolytic if at all it was one. According to the Opposite Party No.2, all witnesses clearly stated that one common feature in anyone carrying haemolytic reaction, billirubin count will be raised to about 7-8 mg. Dr. Nanu, Complainant's witness No.2 endorsed the same. In the instant case the urine discharge throughout was normal and billirubin was with controllable limits. According to the Opposite Party No.2 it is the cardiac arrest which, lasted 4-5 minutes, which resulted in reduced supply of oxygen to the brain. According to him, there are three clear well-established parameters to ascertain or otherwise blood transfusion reaction and these are blood pressure, urine output and billirubin. On all these parameters the case of the complainant is not proved which also clearly signifies that in the present case there was no severe blood transfusion reaction. According to him, the rashes which appeared on the body and chest could not be stated to be severe blood transfusion reaction and since they had disappeared by the time re-exploration was resorted to, there was no ground for sending the blood back to the blood bank for re-examination or its investigation. It is well established that Protamine which is administered at the time of anesthesia is known to cause rashes and allergies including urticaria; the expert evidence clearly states that if there is urticaria we do not take any cognizance of that. It is also admitted by the expert witness that even when a case of blood transfusion reaction is detected the treatment is clinical. According to the Respondents themselves that two basic parameters were observed by the attending physician one is that blood was immediately stopped on appearance of rashes and secondly anti histamine treatment was administered. He was unable to confirm as to why stoppage of blood was not recorded in the record of the hospital. He said that he was informed by the attending physician Dr. Das that transfusion of blood was stopped as soon as rashes appeared. According to the Opposite Party No.2 the infection and septicemia occurred due to recumbency causing catabatic cover barrier, nursing and precaution. The patient was under intensive care protocols all through. It was stated by Col. Suri, Neuro Physician Opposite Parties' Witness No.3 that he had noticed dysfunction of the patient's brain and that this dysfunction in the brain was the result of cardiac arrest. The Opposite Party No.2 has reiterated that severe blood transfusion reaction is almost immediate. It is true that Some of the reactions can be delayed but export witness like Dr. M.L.Gupta and Dr. (Major General) Bose have clearly stated that haemolytic reaction occurs immediately at the time of transfusion. It was argued on behalf of the Opposite Party No.2 that it has not been the complainants case that there was a delayed severe haemolytic reaction. Counsel for the Opposite Party Nos. 1 & 2 have also drawn our attention to the literature on medical negligence by Michael A. Jones in Chapter 3, Standard of Care General Principles which clearly states "..... was the defendant careless? In law the test for breach of duty in the tort on negligence is whether the defendant's conduct was reasonable in all circumstances of the case. If it was reasonable he was not negligent ...." He also rolled upon All England Law Report 1957 (2 All ER 118) Bolam Vs. Friern Vs. Hospital Management Committee as well as All England Law Reports (1981) 1 All ER 267-White House Vs. Jordan & Anr., (1985) 1 All ER 643 Sidaway V. Bethlem Royal Hospital Governors & Ors., 1996 (2) SCC 634, Achutrao Haribhau Khodwa & Os. Vs. State of Maharashtra & Ors. It was argued on behalf of the Opposite Party No.3 that they had supplied blood on the request of the hospital for use to the deceased. In all they had supplied 16 units of which 14 were from professional sources and 2 were from non-professional (relations of the deceased). They were all cross-checked and cross-matched as per the guidelines and practice of all blood banks. They were not made aware of any blood reaction at any stage. They came to know first only when notice was received by them from this Commission. According to them the four critical parameters indicative of severe haemolaytic reaction, are as follows: (i) that blood transfusion reaction is immediate, (ii) urine output is severely affected and constantly reduces leading the ultimate renal failure and (iii) there is breakage of red cells and therefore, haemoglobin count of the patient would continuously show a downward trend, (iv) the billirubin count of the patient will show a stead increase and the conjugated (direct) count is always less than unconjugated (indirect) count. As per the evidence on record blood transfusion reaction, if at all there was one, was delayed; it was not immediate. The urine output was normal till about 23rd June and so on. Haemoblogin in this patient on 19th June was 11.8 gms, on 22nd June it was 14.1 gms., 12.8 gms. on 20th June to 14.4. gms on 27th June. The concentration of conjugated billirubin is more than unconjugated billirubin, in normal circumstances. In this case the direct i.e. conjugated billirubin count was found to be more than the indirect i.e. unconjugated billiburin on the two dates i.e. 19th and 26th June, when tests were carried out specifically for the purpose. This alone is sufficient to rule out any haemolytic reaction. All these recorded parameters, do not at all substantiate the main allegation of the Complainant that there was a severe blood transfusion.
29. We have carefully gone through the records and arguments advanced by both the parties. The basic facts as they emerged are that the patient after having been examined earlier was operated upon for Coronary Artery Bypass Grafting (CABG) Surgery, also known as Bypass Surgery, on 17th June, 1991, the operation was ostensibly successful and the was brought back to the recovery room where he woke up, but as is usual in such cases he was injected with compose. Till about 7 - 7.30 PM his condition and all parameters were found to be normal but at 8 O'clock his pulse started going up and blood pressure came down and the quantity of urine passed by the deceased decreased. In the meantime, his drainage i.e. bleeding from the wound had also increased. He was taken for re-exploration to double check if the bleeding has any surgical cause. The patient was brought back at 11 O'Clock on 17th June to the recuperation room with a finding that the bleeding had no surgical cause, blood was coming out of the raw edges of bones. In fact after that there was no bleeding for about four hours. The deceased had a cardiac arrest at about 3.20 in the morning and he was revived by the attending Cardiac Surgeon Dr. Dass, after which he never regained full consciousness. It was also confirmed by two Neurologists who were called upon to examine the patient. From 23rd June onward the patient started having temperature and later the temperature further went upto 102 to 103 not responding to any of the antibiotics and the patient expired on 1st July, 1991. Even though in the complaint, the Complainant had made 11 allegations of negligence against the Opposite Parties, but on an analysis of the evidence brought forth on record as a result of cross-examination by the Complainants as well as evidence adduced by the complainants as also the arguments advanced by the Complainants' counsel, it appears that the Complainants wish to build their case of negligence on one single point negligence on the part of the Opposite Parties related to severe blood transfusion reaction. After examining the evidence and the material on record, it is unquestionably clear that severe blood transfusion reaction has to be immediate as is stated by Dr. M.L. Gupta, Dr. Nanu and Dr. Bose and secondly there are known indicators of blood transfusion reaction like fall in blood pressure, high billirubin and also the less amount of urine being passed by the deceased. On examination of the record and also the evidence on record it is clear that on all these three parameters it was not possible for the Opposite Party Nos. 1 and 2 to arrive at a conclusion that this is a case of blood transfusion reaction. It is clearly stated by one of the witnesses, who alone went through the record Dr. Saraya that this could not be stated to be a case of severe blood transfusion, if this be a case of reaction at all. The two aberrations relied upon by the Complainants are, the appearance of rashes on the face and body of the deceased on the evening of 17th June and passing of red coloured urine on the morning of 19th June, 1991. Enough medical unrebutted and uncontroverted evidence is on record to substantiate the fact that rashes could be an allergic reaction not necessarily related to the blood but on account of several intrusions (7 to 8 drips) made into the body of the patient. Clear evidence has come that allergic reaction could also related with administration of PROTOMINE, which had been administered on the deceased earlier. This has not been rebutted by the Complainants' side. Within these known parameters it would be very presumptuous to assume that the doctors should have responded in any way different than the way they did. It has been argued by the learned counsel for the Complainants that even though Opposite Party No.2 stated that the blood transfusion was stopped when rashes were seen to be appearing on the chest and face of the deceased but there is no record to this effect. Taking even the wrost case scenario that transfusion was not stooped, even then the expert evidence is that treatment in such case is clinical, which was done in this case. This has not been challenged by the Complainants. It is also a fact that rashes did not recur. Sufficient evidence has been adduced by the Complainants and the witnesses that in case of severe blood transfusion reaction the blood transfusion needs to be stopped and then the bottle is sent back according to understood procedure back to the source of supply for investigation. Since in this case, in the judgement and views of attending Doctors and Opposite Party No.2 no visible symptom associated any way with the blood transfusion reaction was noticed, no action was taken to send the blood sample back to the Opposite Party No.3 for investigation.
30. Another instance is that of passing of red urine on the morning of 19th June, 1991, which is associated with haemolysis, in other words, break down of read blood cells. This is a lone episode on the morning of 19th June for which a single dose of MANITOL was administered, after which urine became clear. There has been no episode before or after date in which urine either was coloured or its quantity reduced. While it is true that passing of red urine could be associated to the haemolytic reaction but evidence is on record to show clearly that it cannot be a case of isolated episode. If one starts passing red or brown coloured urine as a result of severe reaction i.e. break down of RBC's then this is not going to stop by conventional therapy. In the instant case one single dosage of MANITOL was good enough to prevent its reaction, inferring thereby that this was not an instance of haemolysis Again corroborating the case of the Opposite Parties that this was not a case of any blood transfusion reaction. The Complainants had also relied upon the death certificate which states along with others that death was caused by severed blood transfusion reaction. It is pertinent to note that in his evidence, Dr. Mukand Lal Sharma who wrote the Death Certificate, clearly stated that he had relied upon only on record and was not aware of anything else when he write the death certificate. When subsequently asked by the counsel for the Complainant that when he wrote that this was a case of severe transfusion reaction does it imply that the patient had suffered some haemolytic reaction? The answer of the witness Dr. Sharma was "No no. Haemolytic transfusion reaction is entirely a different entity". He goes on to state "It could be severe anaphylaxis, it would be severe haemolytic reaction, it could be severe as even with Glucose, we write as severe reaction, severe does not mean that haemolytic is a different entity". When further asked as to whether his observation is based on this chart which shows us only rashes appearing on the face and the chest, his answer was 'yes'. He also states that he has also seen report of the Neurologist on the subject wherein Senior Neurologist Dr. Janaki has mentioned "(blood reaction)". Dr. Sharma goes on to state "since this National Heart Institute is an institute for teaching and academic institute this will be chronology of the morbid events which we write ultimately leading to death". The witness Dr. Sharma also admits that he was not present through out the length of stay of the deceased in the hospital and his analysis was based on the realm of speculation. His writing of death certificate needs to be seen as one single episode (rashes on body/Dr. Janki's prescription "blood reaction") of blood transfusion reaction chronology reproduced without attributing or meaning more than what the author (Dr. M.L. Sharma) says. Based on this, one does not and cannot form an opinion that the cause of death had anything to do with blood transfusion reaction as no cohesive evidence has been led by the Complainants' side to prove the negligence on the part of the Opposite Parties that the death of the deceased had anything to do with blood transfusion reaction. There is also no material on record to prove that the cardiac arrest had anything to do with blood transfusion; his long illness was one of the main reasons for resistance to antibiotics and his temperature could not be controlled by 26th June leading to septicemia, renal failure and finally to the unfortunate death of the deceased. No nexus has been established between the surge carried out, and, any negligence shown on the part of the Opposite Party No.2. It has repeatedly been stated by all the witnesses that if it was a case of severe blood transfusion reaction then the parameters enumerated earlier like blood pressure, urine output and billiburin count should have changed, but the Complainants completely failed to prove to the contrary in this regard as is evidenced by the records. The Complainants had also relied upon a judgement of Delhi High Court and two judgements of the Supreme Court quoted earlier. According to the ruling of the Hon'ble High Court, "documents filed by the party - It can be looked into at the instance of the Opposite Party - no proof thereof is necessary". The Complainants also relied upon AIR 1987 Supreme Court 2179, Vinod Kumar Arora V. Smt. Surjit Kaur, in which the Supreme Court had held, "The pleadings of the parties form the foundation of their case and it is not open to them to give up the case set out in the pleadings and propound a new and different case". The Complainant also relied upon the judgement of the Supreme Court passed by a larger Bench in AIR 1974 SC 471 Nagain Das Ram Das Vs. Dalpatram Iccharam Alias Brijram & Ors. wherein it was held "admissions, if true and clear, are by far the best proof of the facts admitted and they by themselves can be made the foundation of the rights of the parties". The key words are - 'admissions - if true'. In the reply given by the Opposite Party No.2 as well as affidavit filed by the Opposite Party No.2 the whole sequence of evens and the causes leading to death of the deceased are clearly spelt out, controverting the allegation of negligence on the part of the Opposite Party No.2 emanating from severe blood transfusion reaction and its aftermath. Thus it will be correct to hold that even though the last paras of both the documents quoted above, the Opposite Party No.2 subscribes to the fact that the cause of death is as given in the death certificate, this should be seen as only chronology of events rather than the cause of death. It has been amply demonstrated above, based on record as well as evidence given by Dr. Sharma, the author of the death certificate that "we write as severe reaction, severe does not mean that". Death certificate states the cause of death as Post CABG transfusion reaction (which as the writer of the certificate states on Death is based on appearance of rashes in the chest and face of the deceased on 17th June, 1991) CVA following cardiac arrest, (18th June) Septecemia (23rd to 1st July) and multi-organ failure (1st July, 1991). Prima facie one tends to agree with the statement of the author of the death certificate that it depicted the chronology of events/episodes leading to death.
31. It has been held by the Supreme Court as far as negligence is concerned, in A.I.R. (38) 1951 Supreme Court 177 Sriniwas Ram Kumar V. Mahabir Prasad and Ors., "......there would be nothing improper in giving the plaintiff a decree upon the case which the defendant himself makes. A demand of the plaintiff based on the defendant's own plea cannot possibly be regarded with surprise by the latter and no question of adducing evidence on these facts would arise when they were expressly admitted by the defendant in his pleadings. In such circumstances, no in justice can possibly result to the defendant, it may not be proper to drive the plaintiff to a separate Suit". Key words are "when no injustice can possibly result to the defendant ...". In this case to bar the Opposite Party No.2 to plead int eh case solely on the ground that he has replied that the cause of death is as given in the Death Certificate, which inter alia also refers to severe blood transfusion reaction, will be 'unjust' to the Opposite Party No.1 & 2 in the light of the material on record. Facts of the two cases are also not similar. In the light of the above, the Complainants are not helped at all in invoking the Doctrine of RES IPSA LOQUITUR.
32. The pleadings of the Opposite Parties throughout have been that there has been no blood transfusion reaction and the death certificate relates to the chronological sequence of episodes in the life of the deceased during his stay in the hospital leading to his death. The mere mention of severe transfusion reaction as the cause leading to death does not in our view amount to admission on the part of the Opposite Party No.2 specially in view of the clarification given by the writer of the death certificate that this was not a case of Haemolytic reaction and all the more rebutted by the related parameters which should normally accompany any severe blood transfusion reaction. In our view, the Complainants have failed to prove any element of blood transfusion reaction and its relationship or nexus with the final cause of death.
33. It is argued by the counsel for the Complaints that Opposite Party No.2 was negligent in responding properly to the rashes appearing on the body of the deceased upon the blood transfusion from the seventh bottle. The counsel relied upon the judgment of Lord Fraiser while reversing the judgment of Lord Denning (sitting in Court of Appeals) White House Vs. Jordan & Anr. relied upon by the Supreme Court in the State of Haryana Vs. Santra (Smt.) reported in (2000) NCJ (SC) 308:
"The true position is that an error of judgement may, or may not, be negligent; it depends on the nature of the error. If it is one that would not have made by a reasonably competent professional man profession to have the standard and type of skill that the defendant holds himself but as having, and acting with ordinary care, might have made, then it is not negligence".
34. The counsel also relied upon the judgement of Supreme Court in the case of M/s. Spring Meadows Hospital:
"Very often in a claim for compensation arising out of medical negligence a pleas is taken that it is a case of bona fide mistake which under certain circumstances may be execusable, but a mistake which would tantamount to negligence cannot be pardoned. In the former case a Court can accept that ordinary human fallibility precludes the liability while in the latter the conduct of the defendant is considered to have gone beyond the bounds of what is expected of the reasonable skill of a competent doctor".
35. In order to benefit from the judgement the Complaints which as discussed earlier, the Complainants have failed to establish. Not only no case of negligence, not even a case of mistake has been proved by the Complainants.
36. In the instant case material on record and expert evidence corroborates what was done by Opposite Party No.2. No witness corroborates that rashes could be associated with anything else but allergic reaction for which treatment is antihistamine which was done in this case also.
37. It has also been the effort of the Complaint to link septicemea and jaundice with Blood transfusion. Expert evidence is that Septicemea can arise of blood transfusion only if it is infected First symptoms of septicemea are rise in temperature which in this case occured on the sixth day after the surgery and blood transfusion. No evidence was led by the complainant to prove that the transfused blood was infected nor any circumstantial evidence or otherwise is available on record to accept that the septicemea was caused by blood transfusion. On the contrary, the record shows that this could be on account of prolonged hospitalisation, infusion of so many tubes and lines into the body. I.V. lines, endotracheal tube, manipulation in the intensive care and in spite of full medical cover. This has not been rebutted in any way by the Complainant.
38. We are of the view that negligence as has been laid down by the Supreme Court in its several judgments as well as given in the literature on Medical Negligence by Michael A. Jones, London Sweet & Maxwell 1996, Chapter 3, Standard of Care - General Principles, has not been proved by the Complainants. The main criteria to be seen is whether the defendant's conduct was reasonable in all circumstances of the case. After perusal of the material on record and evidence brought forward, we find that the conduct of the Opposite Parties was more than reasonable and the level of care was as could be expected from a professional, exercising reasonable degree of skill and knowledge. Similar principles were also propounded in Bolam Vs. Friern Hospital Management Committee (1957) 2 All E.R. 118, White House Vs. Jordan and Anr. reported in All England Law Reports (1981) 1 All ER 268 as well as propounded by the Supreme Court in several cases of negligence wherein it was held that the doctors are expected to exercise reasonable amount of care which in this case was exercised by the Opposites Parties. In our view, the Complainants have failed to prove any case of negligence on the part of the Opposite parties.
39. The Complaint is dismissed.
40. No order as to costs.