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2.3     Being aggrieved, by the untimely death of the patient at the age of 37 years, who was working as a Software Engineer and sole earning member of the family, the patient's wife and minor son have filed the instant Consumer Complaint before this Commission and prayed Rs. 3.10 Crore as compensation.   

3.      Defense:

All the OPs have filed their respective Written Versions.

3.1    Reply of Woodland Medical Centre (OP-1)           The Director - Mr. Probir K. Bose filed reply on behalf of OP-1. He submitted that the Complaint is not maintainable against the OP-1. It involves complicated question of facts, which cannot be adjudicated in summary proceedings under the Consumer Protection Act, 1986 and the Civil Court is appropriate to decide such matter. The death of the patient was admittedly an act of negligence alleged to have been committed by the OP-2 and OP-3. Both the doctors were not associated directly with Woodland Hospital - OP-1, therefore, the management of the hospital cannot be held liable especially, there are no allegations of any administrative negligence or failure to provide basic infrastructure to the patient.  Moreover, the patient had a natural death at his home after several weeks after his discharge from the hospital. He submitted that the OP-1 is a day care centre, provides facility for the doctors for their short treatment. Therefore, OP-1 has no major role in the treatment of the instant patient. He further narrated the events happened on the fateful day. The patient was admitted by OP-2 around 9.00 am on 18.06.2008.  At around 10 am, the OP-3 Anesthetist came to Room No. 231. The Matron on duty sent one sister Kakoli Biswas to assist OP-2. The OP-2 took the vials from the patient's bedside locker and placed it on the trolley and made preparation of lumber puncture (LP)  to give intrathecal Chemo injection.  The sister Kakoli followed his instructions only and Dr. Patwari - OP-3 drew up the contents of vials, which he had placed on trolley and kept the injection ready. The LP was done with some difficulty at 3rd attempt and then he injected the medicine intrathecally. After the procedure, the OP-3 left the hospital.  After 15 about minutes, immediately after knowing Vincristine was  wrongly  injected intrathecally, the OP 2 and 3 returned to the patient at 10.45am  and took corrective steps by withdrawing CSF and gave injection hydrocortisone intrathecally. However, both the doctors  have not reported the implication of said error to the hospital or the authority. The OP-2  just mentioned in the record as  'IT-VCR' instead of intrathecal Vincristine. The OP-1 submitted that, the hospital has no opportunity to deal with the patient further as the patient was already discharged and sent to TMH.

6.1.    It is evident from the letter dated 26.06.2008 of Dr. Rajesh Jindel (annex.C/pg119) admitted about the incident and involvement of OP-3. The part of letter is reproduced as below:

Mr. Kuntal Choudhary is my patient who was referred to me from Tata for chemotherapy. He is suffering from diffuse large B cell lymphoma and was advised MCP 842 protocol for treatment He had already received three cycles on this protocol and was admitted for the fourth cycle to Woodlands on 18/6/08. On day one of this cycle intrathecal Ara-C 70 mg is also given. In the previous cycle also I had asked Dr. Sanjay Patawari to give him the intrathecal injections. This time also I requested him to give intrathecal Ara-C. The patient got admitted on 18/06/08 about 9 am I was informed. Dr. Sanjay Patawari came and gave him an intrathecal injection which he soon realized that he had given inj. Vincristine instead of Ara-C. He rang me up telling me of the incident. I rushed to the spot. Before I reached the bed of the patient, the patient also rang me that a wrong injection had been given to him. On my way to the patient I contacted ray friends in Tata over the remedial measures that may be taken now. We decided to drain out the amount of CSF which had been injected from the same spot and pushed 100 mg of inj. Hydrocortisone in an equal volume. Subsequently I discussed this at length with my teachers and colleagues in Tata and made arrangements for the patient to be shifted there for treatment. The patient was admitted to Tata on 20/06/08 late in the evening. This incident was reported verbally to the authorities in Woodlands on 18/06/08 and they were regularly informed of all the developments.

6.2.    The hospital investigated the matter and prepared the  Sentinel Event Recod and Report,  (Anx. D/pg 120) which narrated the   sequence of events  on the date of incident (4th Chemo) .It was noted that the OP-3 had given wrong injection and he did not cross-check the medication details before administration. Dr. Patwari informed Dr. Jindel about the error and arrived to visit the patient, discussed those events with their seniors in TMH over the phone. Both have repeated lumbar puncture and drained 8ml of CSF and gave 100 mg (diluted) in 5ml of distilled water, intrathecally. The matter was discussed with the patient and his father and the patient was discharged on 20.06.2008.

7.4     Was it an inadvertent mistake or an accident ?   

On careful perusal of entire sequence of events and the contemporaneous medical record, in my view, it was neither an inadvertent error nor an accident in the instant case. The cotemporaneous medical record and evidence of nurse clearly prove that OP-3 did not check the medication details before administration. OP-3 prepared the Vincristine, performed LP  and injected the drug  intrathecally, under the impression that it was injection Arabinocide - Cytarabine. After injecting, he left the Hospital, but he was telephonically informed after 15 minutes having given the wrong injection. OP-2 was called to the hospital and after discussion with OP-2 repeat LP was done and drained 8 ml of CSF and also given injection Hydrocortisone through LP. On 20.6.2008 the patient was airlifted to TMH, Mumbai for further management.