DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

PATIALA.

                                      Complaint No. CC/15/3 of 2.1.2015

                                      Decided on:  16.6.2015

Gurmeet Kaur wife of Dr.Gurbakh Singh Gill, resident of H.No.93, St.No.6, North Avenue , Bhadson Road, Patiala.

                                                                   …………...Complainant

                                      Versus

1.      Dr.Gurbakshish Singh Sidhu, Columbia Asia Hospital, Patiala.

2.      Columbia Asia Hospital, Patiala, through its General Manager.

                                                                   …………….Ops

                                      Complaint under Section 12 of the

                                      Consumer Protection Act.

                                      QUORUM

                                      Sh.D.R.Arora, President

                                      Smt.Neelam Gupta, Member

                                      Smt.Sonia Bansal,Member

Present:

For the complainant:   Sh.Manjit Singh, Advocate

For Ops:                       Sh.H.P.S.Verma,Advocate           

                                         ORDER

D.R.ARORA, PRESIDENT

1. It is the case of the complainant that the complainant having suffered from the abdominal pain, she contacted Dr.Parmod Mittal of Model Town, Patiala on 17.8.2014, who advised for ultrasound test and in the said ultrasound test 5-8mm stone was found in Common Bile Duct(CBD) and after going through the report of the ultrasound Dr.Parmod Mittal advised the procedure through endoscopy  for the removal of the stone to be got done from Op no.1, who is working with Op no.2.
2. On 22.8.2014, the complainant contacted Op no.1 namely Dr.Gurbakshish Singh Sidhu at 10 a.m. and who advised that he would remove the stone from the CBD through endoscopic procedure and would charge Rs.10,000/- , which will have to be deposited with Op no.2. Accordingly, the complainant deposited Rs.10,000/- with Op no.2. On the said date at 3pm, she was taken to the operation theater  by op no.1 for the removal of the stone.
3. It is further averred by the complainant that at about 4.15 pm , op no.1 had come out from the operation theater and he appeared worried  and his hands were trembling. He admitted before Dr.Gurbaksh Singh Gill, the husband of the complainant as also her mother Smt.Balwant Kaur that during the endoscopic procedure, a cut had been caused to duodenum of the complainant and her condition was serious and the same required immediate major open surgery and he asked the husband of the complainant to deposit Rs.40,000/- for the operation and he also got the signatures of the mother of the complainant on a paper. The open major surgery was performed by Dr.Surinder Singh, who is also working with Op no.2. The operation continued up to 9-00pm, during which period, no information about the wife of the complainant was given by Dr.Gurbakshish Singh Sidhu, to the husband of the complainant as well as to her mother.
4. Even after the operation of the complainant performed by Dr.Surinder Singh, health of the complainant had deteriorated and during which period Op no.1 failed to enquire about the health of the complainant or tender an apology having caused internal injury to duodenum, by way of negligence and who failed to pay any visit to the patient up to 25.8.2014, up to which the complainant remained admitted in the Columbia Asia hospital, i.e. Op no.2., on which date she was referred to Fortis Hospital, Mohali, because of her serious condition and there being no improvement in her health. When the complainant was taken to Fortis Hospital, at Mohali, Dr.J.D.Wig, treated the complainant and who at the outset asked the husband of the complainant as to whether Magnetic Resonance Cholangiopancreatograthy (MRCP) was got conducted before conducting the Endoscopic Retrograde Cholangio pancreatography (ERCP) by Op no.1 and the husband of the complainant disclosed  Dr.Wig that no such test was advised by Op no.1 although the other tests of the blood were got conducted. The requisite tests to see whether the mouth of duodenum could allow the passage for endoscopic probe were not conducted, going to show that there was medical negligence on the part of Op no.1 as also  deficiency of service on the part of the Ops and due to the lack of the aforesaid tests, the complainant suffered the tearing of the duodenum , which necessitated the immediate major surgery to save the life of the complainant and as a result, the complainant suffered a life threat having suffered serious complications.
5. It is further averred by the complainant that she remained admitted in the Fortis Hospital at Mohali and at the time of the filing of the complaint she was still under treatment. She had to pay Rs.50,000/- for getting the major surgery done from op no.2 and thereafter she spent Rs.1,80,000/- approximately, in getting herself treated from the Fortis Hospital. The complainant also suffered physically, mentally and financially and therefore, she is entitled to a compensation in a sum of Rs.10lacs, for which sake she alongwith her husband approached the Ops but they failed to pay any amount. The complainant got the Ops served with a legal notice dated 31.12.2014, sent through registered AD post on 4.5.2014, calling upon the Ops to make the payment of  the compensation of the aforesaid amount but despite the receipt of the notice, the Ops failed to respond. Accordingly the complainant has brought this complaint against the Ops under Section 12 of the Consumer Protection Act,1986 ( for short the Act) for a direction to the Ops  to pay her  Rs.10lacs  by way of compensation.
6. On notice, the Ops appeared and filed their written version. It is stated by the Ops that the patient Smt.Gurmeet Kaur, had visited Op no.2 on 18.8.2014, with the history of her having suffered from abdominal pain, for which purpose she had contacted Dr.Parmod Mittal of Model Town, Patiala, who advised her ultrasound tests, which revealed the presence of 5.8mm stone in the CBD. On 22.8.2014, the complainant was advised ERCP to be conducted on the same day as the patient was suffering from sever pain. She was advised to deposit Rs.10,000/- towards the medical expenses and for the surgery. After completion of the formalities, the patient and her attendants were explained all the risks and complications, which may happen during or after the ERCP,  despite due care and caution ,  and the consent in this regard was taken. After obtaining the consent, the patient was taken to the operation theater for ERCP and to remove the stone at about 4.30pm. During ERCP sphincterotomy was done for the removal of the stone. During sphincterotomy ( cut of sphincter) , it was noticed that there was a minor bleed and leakage , which were immediately confirmed with fluoroscopy without delay. This is a well known complication in ERCP while doing sphincterotomy. Immediately, the surgeon was called for management of the same and the husband of the patient was also informed about the complication having arisen during ERCP as well as nature of the immediate surgical management required to treat the same. For that sake also the consent was taken. The patient was then taken for surgery at about 5.05pm. The complications were immediately identified and the patient was taken up for surgery well in time , as a result of which the life of the patient was saved and there was no delay whatsoever, which may come with catastrophic outcome, which was avoided timely through surgical intervention. The attendant of the patient was also informed about the revised expenses to be incurred due to the additional surgeries, which is the standard practice in the hospital of Op no.2.
7. It is further averred that the laparotomy with duodenal repair was performed by Dr.Surinder Singh, Sr.Consultant Surgeon and the duodenum was repaired and it was a successful surgery. After the surgery, the patient was shifted from the OT to recovery room and finally to the ward approximately at 9.15 am.The husband of the patient was also informed about the post operative condition. It is denied that at about 4.15pm, op no.1 had come out of the operation theater appearing worried and that his hands were shivering. All other allegations made by the complainant in this regard have been denied categorically by the Ops. It is denied that Op no.1 was not concerned about the health of the complainant, which remained deteriorated or that Op no.1 did not visit to enquire about the health of the complainant, rather Op no.1 informed about the condition of the patient post operatively through Dr.Surinder Singh, consultant surgeon, who explained each and every thing to the complainant and her husband. Since the patient required only surgical management and therefore, there was no need for Op no.1 and it was not necessary for him to visit the patient time and again as the patient was being managed and supervised by consultant surgeon. The patient was progressing satisfactorily. However, on the insistence of the husband of the complainant, she was referred to Fortis Hospital, Mohali but it is denied that the condition of the patient remained serious.
8. It is further the case of the Ops that each and every caution was taken while handling the case of the complainant. MRCP was not indicated  in this case as there was no doubt in the diagnosis of CBD stone as revealed in ultrasound abdomen. The necessity of MRCP investigation is required only in those cases, where there is a doubt of diagnosis of CBD stone from the ultrasound  report because this is an advanced investigation which was not at all required at that stage, as it was clear from the ultrasound reports that there was stone of 5-8mm in the CBD. Even in the Fortis Hospital, as per the reports produced by the complainant, there was provided conservative management only, which  continued at Fortis hospital. The patient was found medically recuperated and did not require any further medical and surgical management, on her follow up visit to Columbia Asia, hospital on 5^th January,2015. It is denied that the complainant had to spend on account of the alleged negligence or deficiency of service on the part of the Ops. The complainant has not paid anything else than the medical and allied charges. It is denied that the complainant suffered physically, mentally and financially. It is denied that she is entitled to a compensation in a sum of Rs.10lac .After denouncing the other allegations of the complaint, going against the Ops, it was prayed to dismiss the complaint.
9. In support of her complaint, the complainant produced in evidence Ex.CA, her sworn affidavit, Ex.CB, the sworn affidavit of  Dr.Gurbaksh Singh Gill alongwith the documents Exs.C1 to C40 and her counsel closed the evidence.
10. On the other hand, on  behalf of the Ops, their counsel tendered in evidence Ex.OPA, the sworn affidavit of Dr.Gurbakshish Singh Sidhu alongwith the documents Exs.OP1 to OP7 and closed their evidence. Here, it may be noted that the deponent of Ex.OPA namely Dr.Gurbakshish Singh has been cross-examined  by the learned counsel for the complainant.
11. The parties failed to file the written arguments. We have heard the learned counsel for the parties and gone through the evidence on record.
12. Ex.C23 is the copy of the ultrasound report dated 17.8.2014 of Bharat Ultrasound Centre, Chhoti Baradari, Patiala by Dr.A.K.Kapila, MD Radiodiagnosis, in respect of the patient Mrs.Gurmeet Kaur, referred  by Dr.Parmod Mittal and the same provides:
5181662. : Liver is normal in size. Both lobes shows normal and uniform echopattern.No focal lesion is seen. Intrahepatic billiary radicles are normal.Portal vein and hepatic veins are normal.

GALL BLADDER is not seen(O/C Cholecystectomy)

COMMON BILE DUCT : Dilated  & measures 6.8mm in diameter. A small intraluminal echogenic mass with distal acoustic shadowing measuring 5.8mm seen in the lower end of CBD.

120632825995. : Normal in size and echopattern. No focal lesion is seen.
220915566. : Normal in size and echopattern. No focal lesion is seen.

RIGHT KIDNEY: Normal in size, site, outline and echopattern.Corticomedullary distinction is normal and well-maintained. No calculus or mass is seen. Pelvicalyceal system is normal and shows no hydronephrosis.

LEFT KIDNEY: Normal in size,site, outline and echopattern. Corticomedullary distinction is normal and well-maintained. No calculus or mass is seen. Pelvicalyceal system is normal and shows no hydronephrosis.

No pre or paraoaritic lymphadenopathy is seen.

IMPRESSION: US FINDINGS ARE S/O CHOLEDOCHOLITHIASIS NORMAL LIVER, PANCREAS, KIDNEY & SPLEEN. For clinical correlation and further evaluation.” Choledocholithiasis means the presence of stones in the Common Bile Duct.

13. It was submitted by Dr.Gurbakshish Singh Sidhu, Op no.1 that with the help of the ultrasound report of the abdomen, presence of the stone in the CBD qua its location was identified in that, it was lying in the lower end of CBD and therefore, ERCP i.e. Endoscopic Retrograde Cholangiopancreatography , which has become the gold standard for diagnosis of choledocholithiasis  was considered appropriate. Dr.Gurbakshish Singh placed reliance upon Ex.C36 an article on Radiology Rounds by Janet Cocheane,D.Phill., covering the discussion on General Guidelines for the Selection of MRCP or ERCP,  Diseases Diagnosed by MRCP Limitation,   Patient Preparation and MRCP Procedure Scheduling,  Further Information, References . It is further discussed, “When patients have  suspected biliary or pancreatic disease, ultrasound imaging is the traditional screening technique. However, ultrasound is limited in its ability to image abnormalities in the biliary and pancreatic ductal systems and further evaluation may be necessary with either endoscopic retrograde cholangiopancreatography (ERCP) or MRCP.

ERCP is a minimally invasive procedure that combines endoscopy with the injection of iodinated contrast agent into the biliary and pancreatic ducts. ERCP has the advantage of combining diagnosis with intervention. In addition, manometry can be performed and the ampulla can be directly visualized .However, ERCP carries a small but significant risk of complications, including pancreatitis, hemorrhage, and performation. At MGH, the complication rate is 1-2% , significantly lower than the national average. In  disease diagnosed by MRCP, MRCP can diagnose the presence of bile duct obstruction and the level of obstruction in most cases. Biliary calculi smaller than 6 mm can be missed although 2mm calculi can be seen in some cases. Primary sclerosing cholangitis can be diagnosed from the multiple irregular strictures seen in the biliary ducts.Benign and malignant causes of  addition, ERCP may be difficult in patients with post-surgical anastomotic complications.

MRCP is a less costly, non-invasive, and sensitive technique for evaluating the biliary and pancreatic ductal systems. In MRCP, multiplanar images are obtained parallel to the oriental of the biliary tree, using an MR sequence that is sensitive to static fluid without the need for exogenous contrast agents. Fluid in the ducts appears bright against the darker tissue. Image post-processing (maximal intensity projection) is used to make multi-dimensional images of the entire biliary tree and the pancreatic ducts. Although MRCP images have somewhat lower resolution than ERCP, MRCP, shows the ducts in their natural, non-distended state and can easily be combined with MRI of the surrounding viscera”.

14. It was submitted by Dr.Gurbakshish Singh, that the ERCP procedure to be adopted by him was brought to the notice of the complainant and he was fully explained the common risks and complications, depicted on page 3 of the Consent for Medical Gastroenterology Procedures, Ex.OP1 including (a) Recurrence of the symptoms/disease,(b) Bleeding,(c) Gagging/discomfort (d) Gassy discomfort/bioating,(e) Throat pain, (g) Pain (h) Perforation (k) Need for surgical intervention immediately at a later stage (m) Remote risk of death and disability that exist with any procedure and (q) Injury to gums/lips, damage to teeth and dental work and death and the same was duly signed by her husband.
15. It was further submitted by Dr.Gurbakshish Singh, that after consent of the complainant she was taken for ERCP and stone removal in the operation theater at about 4.30PM and while doing ERCP the sphinterotomy was done to remove the stone. During sphincterotomy (cut of sphincter), it was noticed that there was minor bleed and leakage . This was immediately confirmed with fluoroscopy without any delay. This is one of the known complication of ERCP while doing sphincterotomy to remove stone. Immediately, the surgeon was called for the management of the same and the husband of the patient was also informed about the condition which had arisen during ERCP procedure as well as nature of immediate surgical management required to treat the complication. In that respect also the consent Ex.OP4 of Smt.Balwant Kaur, mother of the patient, was taken for performing laparotomy. The patient was taken for the surgery at about 5.05PM. The complication immediately having been identified, the patient was taken up for surgery well in time on account of which, the life of the patient was saved. Laparotomy with duodenal repair was performed by Dr.Surinder Singh, Sr.Consultant Surgeon and the duodenum was repaired and that it was a successful surgery. After the surgery , patient was shifted to the recovery room at about 7.50PM and finally to the ward approximately at 9.15PM.
16. It was submitted by Dr.Gurbakshish Singh that as per article Ex.OP3 on “Complications following endoscopic retrograde cholangio pancreatograph : minimal invasive surgical recommendations” by

1) Department of Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey.

 (2) Department of Surgery, Baskent University Faculity of Medicine, Istanbul Research Hospital, Istanbul, Turkey

(3) Department of Surgery, Yuzuncu Yil University Faculty of Medicine,Van,Turkey.

(4) Department of Radiology, Yuzuncu Yil University Faculty of Medicine, Van , Turkey   under the heading  BACKROUND: it provides : ERCP has a complication rate ranging between 4% and 16% such as post-ERCP pancreatitis, hemorrhage, cholangitis and perforation. Perforation rate was reported as 0.08% to 1% and mortality rate upto 1.5%. Besides, injury related death rate is 16% to 18%. In this study we aimed to present a retrospective review of our experience with post ERCP related perforations, reveal the type of injuries and management recommendations with the minimally invasive approaches”. Under the heading METHODS given at page 2 , it is provided: “Records of patients undergoing ERCP was analyzed over a 16-year period, patterning the types of injuries, diagnosis, management, and patient outcome. Type 1 injuries damage the medial or lateral duodenal wall before sphincter cannulation. Type II injuries are periampullary and occur as a result of a precut or a papillotomy. Type III injuries occur secondary to guidewire insertion or stone extraction from the common bile duct. Type IV injuries are probably microperforations that are noted on excessive insufflations during and after ERCP withdrawal”. In the said article on page no.3 under the heading CONCLUSIONS , it is recorded: “In perforation, the mechanism of injury during ERCP predicts the need for surgical management. Type 1 and type II injuries require early diagnosis and aggressive surgery, whereas type III and type IV injuries may be managed conservatively.”

17. It was also submitted by Dr.Gurbakshish Singh, that the perforation in the duodenum was identified immediately after the cut of the sphincter for the removal of the stone and when a minor leak was noticed , in the interest of the patient, the procedure was abandoned as continuing with the ERCP could prove fatal. In that way, it was submitted by Dr.Gurbakshish Singh, that there was neither any negligence nor any deficiency of service on the part of the Ops in treating the patient.
18. On the other hand, it was submitted by Sh.Manjit Singh, the learned counsel for the complainant that the procedure adopted by Op no.1 namely Dr.Gurbakshish Singh Sidhu, in conducting the endoscopy was not proper, in as much as he should have adopted the procedure of MRCP i.e. Magnetic Resonance Cholangiopancreatography, which is a magnetic imaging ducting that uses magnetic resonance imaging to visualize biliary and pancreatography duct in a non invasive manner. He also submitted that it is well proved in current literature that MRCP has the potential to replace diagnostic ERCP in a wide range of bile duct abnormalities, thereby avoiding possible complications related to ERCP. In this regard he made a reference to Ex.C5, an article on Accuracy of MRCP Compared with ERCP in the diagnosis of Bile Duct Disorders by D.Hurter, MB ChB  C De Vries, MB ChB, MMed (Rad) P H Potgieter, MB ChB  R Barry, MB ChB, MMed (Chir) F J H Botha, MB ChB G Joubert, MSc. It was further submittd by Sh.Manjit Singh, that as per article Ex.C4 on Endoscopic Retrograde Cholangiopancreatography , down loaded by the complainant from the site
19. It was submitted by Sh.Manjit Singh, had MRCP been employed by Op no.1 Dr.Gurbakshish Singh, the complication regarding the tearing of duodenum would not have occurred.
20. In this regard, it was submitted by Dr.Gurbakshish Singh, Op no.1 that ERCP is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems  of biliary or pancreatic ductal systems. Through the endoscope, the physician can see inside of the stomach  and duodenum  and inject radiographic contrast into the ducts in the biliary tree and  pancreas so they can be seen on X-rays. ERCP is used primarly to diagnose and treat conditions of the bile ducts and main pancreatic duct, including gallstones, inflammatory strictures (scars), leaks(from trauma and surgery) and cancer. In this regard he had also made a reference to Ex.C4 , the article on Endoscopic retrograde cholangiopancreattography. He also submitted that on the other hand magnetic resonance cholangiography (MRCP) is a medical imaging technique that uses magnetic resonance imaging to visualize the biliary and pancreatic ducts in a non-invasive manner. This procedure can be used to determine if, gall stones are lodged in any of the ducts surrounding the gall bladder. In this regard, he made a reference to Ex.C4.
21. It was further submitted by Dr.Gurbakshish Singh, that in the case of the complainant, there was no confusion about the presence of the stone in the CBD at its lower end as noticed with the help of the ultrasound upper abdomen, Ex.C3 and therefore, there was hardly any justification to go in for MRCP.It was also submitted by him that MRCP is only a diagnostic tool whereas ERCP is both a technique that combines the use of  endoscopy and fluoroscopy to diagnose and treat certain problems  of biliary or pancreatic ductal systems and that ERCP is still employed in the diagnosis of the abnormalities as per article Accuracy of MRCP compaired with ERCP in the diagnosis of Bile Duct Disorders(Ex.C5).
22. It was further submitted by Dr.Gurbakshish Singh that no problem was experienced in the matter of diagnosing the existence of the stone in the Common Bile Duct or even conducting therapeutic  treatment with the help of ERCP, he being MD Pediatrics DM Gastroentrology and having  performed 90 to 100 ERCPs per annum since 2009 and out of the said ERCPs  done by him 90% pertained to CBD as deposed to by him in his cross-examination. He also submitted that the percentage rate of the complications on an overall in CBD, ERCPs is approximately 2 -5%. In this regard he also made a reference to article Ex.OP3 on Complications following endoscopic retrograde cholangiopancreatography minimal invasive surgical recommendations (supra), in which under the head Background, it is provided that ERCP has a complication rate ranging between 4% and 16% such as post –ERCP pancreatitis, hemorrhage, cholangitis and perforation. Perforation rate was reported as 0.08% to 1% and mortality rate up to 1.5%. Besides, injury related death rate is 16% to18%.He further made reference to the said article on page 2, under the heading Methods, which has already been referred to above and which interalia, provides type 1 injuries, damage to the medial or lateral duodenal wall before sphincter cannulation. Type II injuries are periampullary and occur as a result of a precut or a papillotomy.
23. It was further submitted by Dr.Gurbakshish Singh that in the said article on page 5 under the heading Conclusion , it is provided, “Post –ERCP perforation is burdened by a high risk of mortality.Early clinical and radiographic features have to be used to determine which type of surgical or conservative treatment is indicated. Half of patients can be treated conservatively, but in case of sepsis or unstable general conditions, early surgical procedure is indicated as the only suitable chance of recovery”. Immediately on detecting the leak because of the cut in the duodenum, he had called the surgeon namely Dr.Surinder Singh, working in Columbia Asia, Hospital for immediate management of the perforation.The surgery was started at 5.05PM without causing any delay. The patient was shifted to the recovery room at 7.50PM and she was there in the ward at 9.15PM. Thus, there was no lack of efficiency on the part of the Ops in treating the patient.
24. In the case of the citation Malay Kumar Ganguly Versus Dr.Sukumar Mukherjee and others 2009(4)RCR(Criminal), the Hon’ble Supreme Court of India while discussing negligence , made a reference to Bolam v. Friern Hospital Management Committee[(1957)2 AII ER 118] for the following observations: “Where you get a situation which involves the use of some special skill or competence, then the test….is the standard of ordinary skilled man exercising and professing to have that special skill. A man need not possess the highest expert skill; it is well-established law that it is sufficient if he exercises the ordinary skill of an ordinary competent man exercising that particular art…[A doctor] is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art…Putting it the other way round, a [doctor] is not negligent, if he [has acted] in accordance with such a practice, merely because there is a body of opinion which[takes] a contrary view”.
25. In the case of the citation Jacob Mathew Versus State of Punjab and another 2005(3)CLT 358, the Hon’ble Supreme Court of India, observed: “A mere deviation from normal professional practice is not necessarily evidence of negligence. Let it also be noted that a mere accident is not evidence of negligence. So also an error of judgment on the part of a professional is not negligence per se. Higher the acuteness in emergency and higher the complication, more are the chances of error of judgment. At times, the professional is confronted with making a choice between the devil and the deep sea and he has to choose the lesser evil. The medical professional is often called upon to adopt a procedure which involves higher element of risk, but which he honestly believes as providing greater chances of success for the patient rather than a procedure involving lesser risk but higher chances of failure. Which course is more appropriate to follow, would depend on the facts and circumstances of a given case. The usual practice prevalent nowadays is to obtain the consent of the patient or of the person incharge of the patient if the patient is not be in a position to give consent before adopting a given procedure. So long as it can be found that the procedure which was in fact adopted was one which was acceptable to medical science as on that date, the medical practitioner cannot be held negligent merely because he chose to follow one procedure and not another and the result was a failure.”
26. In our case Dr.Gurbakshih Singh, Op no.1 adopted ERCP procedure for the removal of the stome from the Common Bile Duct, which procedure is still being employed and the same is a safer and more accurate diagnostic alternative as discussed in the article Endoscopic Retrograde Cholangiopancreatography, Ex.C4 under the heading Diagnostic . Here , it may be noted that Dr.Gurbakshish Singh in his cross-examination stated that ERCP was done because the purpose was to cut the sphincter for the removal of the stone and when the sphincter was cut, a minor leak was noticed and for the benefit of the patient , the procedure was abandoned  as continuing with the ERCP could prove fatal. In the article,Ex.C4(supra) under the heading procedure on page 3, it is recorded: “The sphincter of Oddi is a muscular valve that controls the opening ampulla.The region can be directly visualized with the endscopic camera while various procedures are performed . A plastic catheter or cannula is inserted through the ampulla and radiocontrast is injected into the bile ducts and/or pancreatic duct. Fluoroscopy is used to look for blockages, or other lesions such as stones.When needed , the opening of the ampulla can be enlarged (sphincterotomy) with an electrified wire(sphincterotome) and access into the bile duct obtained so that gallstones may be removed or other therapy performed”. Thus Dr.Gurbakshish Sing, Op 1 had adopted the proper procedure for the removal of the stone from the Common Bile Duct but when he cut the sphincter , he observed a minor leak and he though better to call for surgeon for treating the leak because otherwise it could prove fatal for the patient. In the said article Ex.C4, under the heading Risks, it is noted: “Gut perforation is a risk of any endoscopic procedure, and is an additional risk if a sphincterotomy is performed.As the second part of the duodenum is anatomically in a retroperitoneal location ( that is, behind the peritoneal structures of the abdomen),perforations due to sphincterotomies are also retroperitoneal. Sphincterotomy is also associated with a risk of bleeding”.The risk of bleeding being involved in sphincterotomy, the doctor can not be blamed. We are of the considered view that Dr.Gurbakshish Singh, Op 1 acted prudently having called the surgeon Dr.Surinder Singh to tackle the problem of minor leak(bleeding) in order to safe the life of the patient and the patient had recovered from the problem of the cut of the duodenum .
27. When the patient was taken to Fortis Hospital,Mohali on 25.8.2014 as per discharge summary Ex.C14, she was diagnosed for ‘Post ERCP Duodenal Injury’. Present illness was noted as : “ Patient presented with H/O pain in abdomen. Patient initially admitted in Columbia Asia Hospital USG Abdomen showed Choleldocholithiasis  ERCP was done and patient had duodenal injury during the procedure for which exploratory laparotomy was done on 22.8.2014 at Columbia Asia. Post OP patient had bilious drain 1 liter on 1^st day and 800ml on 2^nd post OP day.Then brought to FHM for further management”. On physical examination the patient was found to be: “ conscious, well oriented to time, place and person No pallor, no cerus, no clubbing, no lymphadenopathy, no pedal adema. B/P -130/80 mmHg, Temp. -98.6f, Pulse rate-80mm, Respiration rate-18/mm, SPO2-99% on room air. Chest-B/L air entry normal,CVS-S1 & S2 normal,CNS-NAD, Abdomen-Soft,EL incision+ Abdominal drain present-High Bilious Output” Under the heading  Course in the hospital , it is noted: “Patient was admitted in ICU with above mentioned complaints initial investigations showed Hb-8.5,TLC-12 2 thou/uL with 85% neutrophills, SGOT/SGPT-33/114, Lipase-315, amylase-91.Urine examination showed yeast cells. Patient was started on IV fluids. IV antibiotics (Inj. Metrogyl,Inj.Magnex),antacids, analgesics and other supportive treatment.MRI MRCP showed There is e/o hyperintense fluid in GB fossa and sub-hepatic region with drainage tube seen in situ along the inferior hepatic surface and the duodenal wall, Mild wall thickening of the adjacent 2^nd part of duodenum is also noted. The liver is enlarged  measuring 18.6cm and shows mild fatty infiltration. Mild bilateral pleural effusion is present. Heterogenous sub cutaneous edema and fluid is also seen in the right hypochondrium region along the drain. CT whole abdomen showed Mural thickening of the first and second part of duodenum without any evidence of oral contrast extravasation and there is No free fluid in  Morrison’s pouch or the visualized retroperiloneum. Patient was shifted to ward on 27.8.2014.Patient had swelling in flank region. USG abdomen  was done which showed Grade 1 fatty liver. Patient pain abdomen persisted. Repeat USG Abdomen showed Prominent CBD with internal echoes-? Sludge,minimal fluid(3-4) is seen in the Morriscns pouch around in situ. No definite collection. Patient was continued on conservative management. Patient improved, is now being discharged with the following discharged advice”.
28. Thus, a perusal of the discharge summary ,Ex.C14, would go to show that no abnormality was observed in the Fortis Hospital being the impact of the ERCP done on the patient. No special treatment was imparted to the patient. MRI MRCP done in the Fortis Hospital showed: “There is e/o hyperintense fluid in GB fossa and sub-hepatic region with drainage tube seen in situ along the inferior hepatic surface and the duodenal wall, Mild wall thickening of the adjacent 2^nd part of duodenum is also noted. The liver is enlarged  measuring 18.6cm and shows mild fatty infiltration. Mild bilateral pleural effusion is present. Heterogenous sub cutaneous edema and fluid is also seen in the right hypochondrium region along the drain”. The same are not shown to be the out come of the surgery performed in the hospital of Op no.2 and therefore, we can safely say that  neither there was any negligence nor  any deficiency of service on the part of the Ops in treating the patient. Op no.1 did his best to over come the problem of the cut in duodenum, which was an anticipated complication, in respect of which Op no.1 had apprised the husband of the complainant vide consent, Ex.OP1 and thus the attendants of the patient also new about the common risk of perforation of duodenum or CBD. Consequently, we do not find any substance in the complaint and the same is hereby dismissed.

Pronounced

Dated:16.6 .2015

                   Sonia Bansal                Neelam Gupta                        D.R.Arora

          Member                        Member                                  President