A. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION : AT HYDERABAD
C. C. 35/2007
Between:
1. Peram W/o late
Aged about 42 years,
2. Peram
s/o late aged about 23 years,
1 and 2 are Guntur District.
3. Y. W/o Muni Reddy,
D/o late
Aged about 21 years,
R/o
Sathenappali … Complainants
And
1. Dr. P. V.
Son of not known to the complainants
Aged about years
2. Dr. P.
w/o Dr. P. V. aged about years,
Both are C/o
Gowri ,
Guntur Town and District … opposite parties
Counsel for the Complainants : M/s. M. Counsel for the Opposite parties : M/s. V.
CORAM :
Hon’ble Sri Justice D.
Sri ……
And
Sri R.
Wednesday, the Twenty Seventh Day of January, Two Thousand Ten
Oral order : ( as per Sri
********
The complainants 1 to 3 are wife and children respectively of the deceased treatment given by Opposite Parties to the deceased patient, he died and they gave a treatment for dog bite instead for snake bite.
The facts as set out in the complaint are that on 16.4.2006 the deceased patient along with other farmers went to agricultural field and while returning in the evening at 5.00 PM he was bitten by a snake. After bringing him home he was taken to Nanda Hospital at Guntur for treatment but the doctor was not available so he was taken to given to the patient . As per the treatment details, the patient was treated for dog bite instead of snake bite. Though the doctors are not experts to undertake treatment for snake bite, however, to squeeze money they admitted the patient. The first complainant had paid a sum of Rs.7 On the next day of admission, the The said hospital in turn referred the patient to Govt. General Hospital, Guntur, where, doctors have expressed that due to wrong treatment of dog bite the condition of the patient became worse advising to take back the patient. While returning home the patient succumbed. After taking home a report was given to the police who registered the FIR and sent the dead body to the post mortem. The doctor has opined that the death of the person was due to snake bite but not by dog bite.
OP. no. 1 filed counter affidavit denying the allegations made in the complaint. It is stated that he along with OP 2 have established Super Specialty Hospital at Guntur about 15 years back. After doing MBBS degree from JIPMER, Chandigarh in distinction. His wife is also a Neurologist having MD DM qualification. Their hospital is having latest equipments and recognized by State Government for reimbursement of the claims of Government employees. It is further stated that the deceased patient was admitted for treatment but it is incorrect to state that on 16.4.2006 the complainants have informed that the deceased patient had snake bite and the allegation that they gave wrong treatment for dog bite instead of snake bite are denied. The patient was brought to the hospital on 16th April, 2006 at about 9.00 PM and was discharged on 17.4.2006 at 12.00 Noon. The history given by the attendants of the patient was that the patient had burning pain in both lower limbs since four days and for the last one day the patient was restless, altered and hydrophobia, moving all four limbs was irritable. Pulse rate was 98/per minute, BP was 170/110, respiratory rate was 28 per minute, pupils were dilated and reacting. There was no evidence of external or internal bleeding. tube aspiration from the stomach was clear, urine through catheter was also clear. A provisional diagnosis of brain stem encephalitis ? Rabies was made. It was a very serious condition which was explained to the attendants. Routine blood investigations were done along with ECG and CT scans etc. He was given antibiotics, anti oxygen and IV fluids. There was suspicion of Rabies Guntur. The common concept was that Rabies is caused by dog bite only . But the history in the present case was only less than 50% of the cases. Rabies is not only caused by dog bites but also by licks of dog, cats, rats, wolves, jackals, bats, rabbits, monkeys etc. From the time of animal licks or bites the person to the manifestation of the disease is called incubation period. The time taken by the pathogenic organism, to multiply in the human body to manifest its effects as the disease. The incubation period raises from 10 days to many years. Rabies disease effects nervous system leading to severe irritation and excitement of nervous system and muscles. and for that reason the patient developed severe cramps of muscles and symptoms of hydrophobia etc. Even ECG reveals the twitching artifacts. If there is no history of dog bite it cannot against rabies because (1) the bites of animals are generally remembered by people. But the licks are generally passed unnoticed and not remembered by the patient. (2) since incubation period is long most of time it is forgotten. It is further stated that there was no symptoms of snake bite exhibited by the patient. The symptoms of snake bite, which is a hallmark of will be bleeding from gums, nose, mouth, bleeding from stomach manifesting as blood vomiting and also bleeding from the injection sites where it was bitten The snake bite will effect blood clotting mechanism and the blood does not clot at all. This is called DIC – Disseminated Intravascular Coagulation/consumption DIC diagnosis can be made only when the patient is alive. It cannot be made after the death of the patient, by post mortem. Even in the OPD ticket of the Government ID Hospital, Guntur also, , there is no symptom of snake bite given by the attendants or any bleeding manifestation noticed on examination. The doctors of Govt. ID hospital would have mentioned of the history of the patient and signs and symptoms so also fang marks and bleeding manifestations. In the Govt. ID hospital prescription it is mentioned that the diagnosis was ? encephalitis. There is no mention of snake bite at all. The Government ID hospital referred to the patient to Neurology dept of Govt. General Hospital, Guntur . And the said hospital had not referred the patient to a specialist to confirm snake
bite which indicates that there was no signs and symptoms of snake bite at all.. The disease manifestations of snake bite and rabies are quite different. The Post mortem report was incorrect and unscientific. The Postmortem was done 18 hours after the death. It is noted in the Postmortem that blood was oozing when the internal organs were cut. It is a normal phenomena called Post Mortem leading to oozing of blood from all organs. This is a normal Postmortem finding. So on this basis alone it cannot be concluded that the patient died due to snake bite. There is no basis to state that there were fang marks on the body of the patient as noted in Postmortem report. One can say it as puncture marks. Nobody can say snake fang marks and there is a puncture mark made by needle. One cannot opine the puncture marks as snake bite marks. The RFSL gave opinion that no chemical poisonous substance was found in the blood. If the patient was bitten by snake even after three days of the death of the patient, snake venom would found in the Postmortem examination. So it cannot be said that the cause of the death of the patient was snake bite as per PM report. Before the deceased patient was admitted in the hospital on 16.4.2006 at 9 PM, prior to that he was taken to Hospital, Guntur. The other hospital are not absolutely incorrect that the complainant had paid Rs.2 The complainant applied to the government under compensation from Government she asked them to give a certificate as if the patient died of snake bite but it was refused. Thereafter the complainant requested the Ops to pay compensation of Rs.5
During the enquiry, the first complainant filed her evidence affidavit and Ex. A1 to A17 documents in support of the case consisting of the final report given by the police, death certificate of PM
certificate, FIR, inquest report. The discharge summary given by the OP hospital etc along with the copies of the legal notice. The Ops have also filed affidavit evidence along with the Ex.B1 to B3.
An Advocate Commissioner was appointed for recording the cross examination of the witnesses of PW.1, Pw.2 and Two other doctors filed affidavits in support of the stand taken by RW. 1 and they were cross examined and their cross examination was recorded by Advocate Commissioner.
PW. 1 in her evidence affidavit simply reiterated the factual aspects of the allegations that in spite of the appraisal of the fact that the deceased was bitten by snake, the treatment for dog bite which had a fatal effect. To support her version and prove the PM report given by the Govt. doctor PW 2 was examined.
According to PW 2 during his government service from 1994 till the date of his evidence he had conducted about 4000 post mortems and about 35 to 40 there will be changes in brain.
During his cross examination he was pointed out that in the inquest report Ex A8, there is no mention of any external injuries on the body. He was also suggested that he had not called for the case sheet of OP s hospital where the patient was treated. He answered that it is not necessary to get the case sheet unless he has any doubt as to the cause of the death. He was also suggested that he had not recorded the conditions of the internal organs whether the same are normal or not. He was also suggested that he has not sent the blood for analysis. He was also suggested that he had not mentioned about the rigor mortis in the PM report for which he has explained that there was no decomposition changes on the body so he has not mentioned it. He was asked to state whether he is aware that the patient was treated for rabbis in hospital. It was also suggested that if ante coagulation was given before death blood oozing will be present in Post mortem, which he has admitted it to be correct. It is also suggested that the DIC can be detected clinically only when the patient was alive and it cannot be seen it in Postmortem, which suggestion he had denied stating that since he diagnosed it as a case of DIC. He has admitted that he is not aware of anti coagulation were given prior to death. There will be blood in heart and blood vessels. He also admitted that no histopathology adrenal gland was done and he cannot say whether histopathology of adrenal gland will give 100% result to detect DIC. Further he admitted that he had not heard as to the allegation that the patient was treated for dog bite either by the police or by the attendant of the deceased. He also deposed that the forensic laboratory report reveals there was no chemical poisonous substance in any of the organs sent for analysis. The witness is questioned on what basis he had given final opinion stating that the cause of death was due to snake bite ?, for which his answer is that since he conducted 35 to 40 snake bite cases, in some cases, the FSL report have shown negative results. To his knowledge gained from forensic medicines the within 24 hours from the death keeping 4 degree centigrade. As per his examination of the dead body and PM findings, available over dead body he came to the conclusion that the deceased died of snake bite. He was further questioned what would be result of Postmortem report in case of rabies death for which he answered that all organs are congested. The FSL report would reveal that virus present. He was suggested that he gave false opinion contrary to the forensic laboratory report.
RW1 ( OP1) has reiterated the factual aspects given in his evidence in chief stating that after admission of the deceased patient, it was diagnosed that the patient was suffering from encephalitis ? Rabies ? The encephalitis has lot of causes for example viral infection like rabies virus or and non infectious causes virus like metabolic abnormalities. The reasons why he put ? Rabies is his clinical feature which is very much suggestive of that cause. It is further stated that there is no definite laboratory investigation to confirm the rabies, anti-mortem. No reference letter of hospital was shown to him at the time of admission. The OP ticket of I.D. hospital reveals that after examining the patient and taking history he was referred to Govt. General Hospital, Guntur but no treatment was given there and he is not aware whether any treatment was given at Govt. hospital. He also stated what all the medicines that were given were mentioned in the case sheet issued by him. Rabies is a dangerous disease of 100% mortality. A High risk consent was taken and admitted the patient for giving treatment. Witness also stated that he obtained a letter dated 2.2.2008 obtained from the Dist. Collector, Guntur under Right to Information Act, about the monitory sanction given to the complainant under
RW. 2 a Medical Practitioner at Guntur having experience in forensic medicine has stated that he gave evidence affidavit at the request of Ops mentioning the General symptoms of rabies pointing out that the symptoms of snake bite will be different from dog bite and both symptoms are not similar to each other. In RW 2 he gone through PM report in which treatment particulars are not noted. Any poison is a chemical . There is no difference between chemical poison and animal poison. Out of 500 Postmortems conducted by him consisting of 30 snake bite cases. And he has also seen the studies of rabies death Postmortem. In case of Rabies death PM examination it looks like a natural death, signs of asphyxia and histological asphyxia inclusion of congestion of all organs and PM fluidity of blood. The PM report will not be exhibited in cases of death due to any Indian snake bite except two fang bites other external symptoms in PM examination are in pre-determined one. However, the internal findings as per PM report does not relate to snake bite at all.
RW.3 another medical officer also gave affidavit in support of the OP 1’s version that he is having qualification of FRCS and a senior doctor. He states that he used to refer cardiac and neurology cases to OP and vice versa. The to show that the deceased underwent treatment under him since 1996 He maintained the case record that the deceased patient whenever he visited for consultation. The deceased patient came to him on 14.4.2006 for burning sensation while passing urine so the phone message is noted in Ex. B3.
The learned counsel for the complainant relying on the Inquest report Ex. A8, and Ex A6 PM certificate has urged that there is satisfactory evidence on record to establish that the deceased patient died of snake bite, while so the OP doctors have treated him on the premise that it was either dog bite or encephalitis and they could not establish that the patient had either dog bite or encephalitis. So the act or omission on the part of Ops in giving wrong treatment would amounts to gross medical negligence especially when the patient attendants have informed that the snake had bitten the deceased while he was returning home from his fields.
On the other hand, the learned counsel for the
It can be said without any hesitation that the patient was not bitten by any snake at all and he was suffering from serious ailments and that the patient was admitted in OP.1’s hospital on 16.04.2006 at 8.00 PM when he had sudden restlessness. Ex B2 record clearly establish that clinical tests were done and from the symptoms it was suspected that the patient was suffering from encephalitis or have the symptoms of rabies virus or Licking by dog or bite which was not within the knowledge of the patient There is no evidence on record to show that the diagnosis or treatment given by the It is a common knowledge that on the admission of a patient in the hospital, the history of the patient sickness will be ascertained either from the patient or the attendants. After ascertaining the details the doctor will record the symptoms to diagnose the disease or the cause on the basis of the clinical reports. Ex. A14 and Ex B2 consists of details of the treatment given to the deceased patient by the when he was admitted on 16.4.2006 at 9 PM till he was discharged on 17.04.2006 at 12.00 noon. If really any of the attendants of the patient had informed to the that the patient was bitten by snake on 16.4.2006 at 5.00 PM, this fact must have been noted in the medical record maintained by the OP.1 or in Ex. B3. On the basis of the signs and symptoms noted in it the Opposite Parties have proceeded with the treatment. The record shows that life saving drugs and also necessary treatment was given as required while he was treated as in patient. It is pertinent to note that the complainants themselves have admitted that when the deceased was brought to home by the other co-worker, the deceased was taken to Hospital at first and since the doctor was not available there they have taken to him to back ground and earlier ailments of the patient. RW.3 has filed Ex B3 along with his evidence. A cursory look of Ex. B3 reveals that right from 27.1.2004 up to 16.4.2006 from time to time the deceased was consulting RW. 3 for his ailments and the treatment taken. It is seen from Ex. B3 that the deceased had consulted the doctor on 15.4.2006 and again on the morning of 16.4.2006 for his suffering. On 16.4.2006 at 11.30 AM some clinical tests were done by RW.3 to diagnose the deceased. All these details are noted in Ex. B3 and on the same date blood test was also done. In Ex B3 it is noted that on 16.4.2006 at about 8.00 PM the patient was found to be having tremors and irrational symptoms. A question was put showing symptoms of meningitis. RW.3 made a note that OP 1 may be referred for further diagnoses. It is but natural that whenever the patient was referred to a super specialty hospital, the said hospital would admit the patient to find out the cause. So the OP doctors in good faith have admitted and proceed with the treatment. If really the patient had a snake bite on 16.4.2006 at 8.00 PM when he was taken to RW.3’s hospital at first at 8.00 PM, the fact that the person was bitten by a snake would not have been missed in the case sheet so also when he was taken to OP 1 on 16.4.2006 at 9.00 PM it would not have been missed or appraised. As there was no response to the treatment and there was situation of health, the OP 1 had suspected that there are symptoms of Hydrophobia which may be due to rabies virus, so he had referred the patient to infectious disease hospital, Guntur, which is also admitted by the complainants in their pleadings. But the Out-patient ticket issued by the ID hospital is not filed by the complainant . Ex. A17 is the OP ticket issued by the Government hospital in which it is noted that the patient had treatment in outside hospital and noted the systems as hydrophobia or encephalitis. But the concerned doctor noted that there no history of dog bite at all. Whatever it may be basing on the signs and symptoms exhibited by the deceased patient the OP doctors were under the impression that the cause may be due to encephalitis or rabies disease. When the Government Hospital had not admitted the patient, the patient was taken back to home and he died on the way. So after reaching their village the matter was reported to the Ex. A4 to the police . In Ex. A4 report it is noted that the deceased due to snake bite. Pursuant there to , the police have registered FIR U/s. 174 Cr. P.C. and conducted a snake had bitten him and the wound started bleeding. After taking the deceased to his house, his wife along with Guntur and joined in a private hospital for taking necessary treatment and while undergoing treatment the deceased died. The dead body was sent to post mortem examination and the Govt. doctor conducted post Mortem and gave Ex. A6 PM certificate. The doctor was examined as PW.2. stating that on the basis of the PM findings he gave opinion that the death was due to snake bite. But the chemical examination report Ex. A5 shows that no chemical poison was found. However, PW.2 gave his final opinion, stating that in continuation of his Ex.A6, Postmortem Certificate, confirming that the deceased died of DIC ( Disseminate intra vascular Coagulation) as a result of snake bite and the appropriate time of death was 18 to 24 hours prior to PM examination.
During hearing the learned counsel for the Opposite parties have filed medical literature of the authors Harrisons Internal Medicine and Parks Text Book on preventive and Internal medicine, in support of their stand and with regard to the clinical manifestations of rabies. The details of it show that the manifestations of brainstem dysfunction begin shortly after the on set of the encephalitic phase. Hydrophobia – the painful violent involuntary contraction of the diaphragmatic, accessory, respiratory, pharyngeal and laryngeal muscles initiated by swallowing liquids. it is seen in 50% of cases. The patient lapses into coma, and involvement of respiratory centre produces an on the essentials of forensic medicine and toxicology authored by K. S. regard to the Post mortem fluidity of the blood shortly after death the blood is usually fluid, and when it is removed from the body, it undergoes spontaneous coagulation. If the autopsy is done a few hours after death, the blood may be clotted and partly fluid. In most deaths from asphyxia , the blood is fluid and The post mortem fluidity of the blood is due to presence of
We have gone through oral and documentary evidence in detail and at the outset it can be said without any hesitation that there is no evidence on record to show that the deceased was bitten by snake on 16.4.2006 at about 5.00 PM as alleged. Non disclosing of the fact to RW.2 about the snake bite at the time of admission at Hospital covered by Ex B3 or at the time of admission in “ Men may lie but the circumstances will not lie “ . This is an acceptable truth which is clear from the circumstances on record. When the Government General Hospital, Guntur have not admitted the patient on account of his serious condition, the deceased was taken back to his village and then a report was given to It appears that some deliberations were made in giving a report alleging that the deceased died of snake bite. The possibility of deliberations cannot be ruled out. The OP 1 has filed a copy of the representation Ex B1, given by the complainant on 13.6.2006 addressed to the District Collector, Guntur, appealing for sanctioning that herself and her husband are agricultural coolies and eking out their livelihood and on the death of her husband she has no source of income at all. From this it can be said that from her own commitment. it can be said that she had no capacity at all to pay a lump sum amount of 12.00 PM . This circumstance also falsifies her version. From the evidence of RW. 2 and 3, it can be said that it is not based on scientific analysis or based on any medical literature. RW.1 to 3 are more qualified and competent doctors in the filed of medicine who are having better experience in the field. When the FSL report shows that there was no poisonous substance either in the it cannot be said that the deceased died of snake bite. Significantly in Ex. A-6, Post-mortem report, PW.2 has not at all mentioned the external injuries so also the external injuries are not noted in the inquest report. In the cross examination of PW. 2, he himself expressed his own doubts in coming to the conclusion in conforming as to the cause of death due to snake bite. RW. 2 who has also having knowledge in forensic science had conducted several postmortem examinations has given his own findings to throw any extent of doubt in the final opinion Ex. A6 given by PW 2 doctor. Thus, the evidence on record is not satisfactory to hold that PW.1 and 2 have committed any medical negligence either in diagnosis or that they gave any wrong treatment to the deceased patient.
For the aforesaid reasons and discussion we hold that the complaint have failed to establish that there was medical negligence on the part of the Opposite Parties and consequently complaint is liable to be dismissed. But in the circumstances there is no order as to costs.
PRESIDENT
MEMBER
MEMBER
Dated : 27.01.2010.
