JUDGEMENT (PER JUSTICE RAM SURAT RAM (MAURYA), PRESIDING MEMBER 1. Heard Mr. S. Ramamoorthi, Advocate, for the complainant and Dr. Lalit Bhasin, Advocate, for the opposite party. 2. N.V. Chandramohan has filed above complaint for directing the opposite party to (i) refund the amount deposited by him; (ii) pay Rs.3/- crores, as compensation for loss of income; (iii) pay Rs.2/- crores, as compensation for pain, mental agony and disability; (iv) pay Rs.500000/ as litigation costs; and (v) any other relief, which is deemed fit and proper in the facts and circumstances of the case. 3. The complainant stated that he had pain in his left knee in March/April, 2014. The complainant went to the hospital of the opposite party in 3rd week of April, 2014 for his treatment. After examination, the doctors advised to undergo for a surgery, in which, he would be discharged within 2 days after surgery and assured that thereafter he could walk normally without any pain and discharge all of his work. Trusting upon the advice of the doctors, the complainant was admitted in the hospital on 16.04.2014 as patient No.C-30209. The doctors performed surgery of the complainant in the hospital on 18.04.2014. After surgery, both the legs of the complainant were paralyzed and he could not even stand. After examination, the doctors informed that due to wrong administer of anaesthesia, this problem had developed, which would be cured with medication. The complainant remained in the hospital for about 8 months continuously under the treatment of the opposite party but of no result. The complainant remained bed ridden with acute pain in the hospital throughout. Ultimately the opposite party discharged the complainant on 08.08.2014. During treatment, the opposite party charged Rs.100000/-. At the time of discharge, the hospital had given bill of Rs.10/- lacs but realizing their mistake in treatment, the opposite party did not insist to deposit the bill. After few days of discharge, the complainant consulted Ayurveda College Hospital, Coimbatore, where he was admitted on 01.09.2014 and remained in treatment till November, 2014. At that time, the complainant was 63 years old and he was doing business of manufacture and sale of silver anklets and ornaments. He was also a manufacturer of power loom woven clots and exporter and was very active in his business. Due to negligent and irresponsible treatment as provided by the opposite party, the complainant had been paralyzed in both of his lower limb and unable to stand. The business of the complainant was destroyed and his future has become miserable. The complainant gave a legal notice to the opposite party, calling upon to return Rs.100000/- charged for treatment and pay compensation of Rs.5/- crores, for suffering, mental agony and permanent disability. The opposite party gave reply notice dated 03.12.2014 and denied of committing any negligence and stated that disability suffered was known as “Cauda Equina Syndrome” due to diabetes. Thereafter the complaint was filed on 15.12.2014. 4. The opposite party filed written version on 01.05.2015 and contested the complaint. The opposite party stated that Kovai Medical Centre and Hospital (the hospital) was a Multi-speciality Hospital, equipped with advance techniques in medical science, which conform to the best possible standards of care and precaution. The hospital provides specialized diagnostic, surgical and curative care in various disciplines through the expert consultants in respective fields of medical science, who adopt well recognized standard procedure and discipline. The complainant, who was 63 years old, came to the hospital on 02.04.2014, complaining severe pain and stiffness in the left knee, with swelling, from last 2 months and also informed that he was diabetic and was on intermittent oral hypoglycaemic agents. The complainant was examined as an out-door patient by Dr. A.S. Thennavan, Senior Consultant Orthopaedician. On his pre-operative visit, his random blood sugar was 116 mg, which was normal and he did not have any symptoms of systematic involvement in diabetes. On examination, the doctor found ‘joint bone tenderness with limited range of movement associated with pain’ in left knee. X-rays revealed Grade IV Osteoarthritic changes. There was no distal neurovascular impairment. General condition of the complainant was stable. The doctor counselled the complainant on various treatment options, which included conservative as well as invasive treatment in the form of knee replacement surgery. The pros and cons of both types of treatment were explained to the complainant. At that time anti-inflammatory medicines were prescribed. The complainant came back on 16.04.2014 and elected for knee replacement surgery. He was again explained about the risk involved in such surgery, particularly about the risks for diabetic and hypersensitive patients. The doctor apprised the complainant about the anaesthetic procedure adopted in such surgery in detail viz. spinal epidural anaesthesia as well as nerve block procedure and the risks involved in it. After considering everything, the complainant gave ‘informed consent’ for surgery and anaesthesia. It has been found in various studies that epidural anaesthesia/analgesia improves the post-operative outcome by relieving pain, reducing pulmonary complications, allowing early mobilization and shortening the length of hospital stay. After anaesthetic and cardiac evaluation, the complainant was prepared for ‘Total Knee Replacement’ on 18.04.2014 under spinal epidural analgesia and nerve block (sciatic and femoral nerve). Standard care was taken, internationally recognised anaesthesia procedure was followed and standard anaesthetic drugs were used, in administering the anaesthesia, both during knee replacement surgery on 18.04.2014 and post the surgery. The complainant complained of lack of sensation and movement in his legs on 20.04.2014, in the morning. Then he was examined by the stream of the doctors comprising of anaesthesiologist, neurosurgeon, neurologist, urologist, diabetologist etc. The tests MRI Spine, Potassium, HBA1C, ANCA, Procalcitonin, ESR, Total and different count, ANA, CRP, ENA6, profile, CSF (chloride, globulin, glucose, protein cells, cytology, AFB-PCR), MRI D spine with brain screening, Electro Myogram (EMG), Nerve conduction study (NCS), MRI contrast Study, Nerve and Muscle Biopsy were done and report from NIMHANS Bangalore was obtained to diagnose and treat the disability. EMG and NCS were suggestive of severe cauda equine lesion involving L4, 5 and S1 nerve root and there was severe axonal loss. CSF analysis showed inflammatory CSF with elevated protein and lymphocytes. The weakness was sensory level up to L2 and motor level up to L1. The tone was reduced and power was 0/5 from thigh downwards. Deep tendon reflexes were absent. The complainant was diagnosed with an acute myelitis/arachnoiditis and was given IVIG (Immunoglobulin) on 06.05.2014, which continued for 5 days. Nerve and Muscle Biopsy were done on 14.05.2014, which showed chronic axonal neuropathy consistent with diabetic neuropathy. The complainant was then given programmed physiotherapy which showed a moderate improvement and his motor power had improved from 0 to MRC 3/5 the legs started moving independently and could turn around in the bed showing truncal muscle improvement. As suggested by the complainant, opinions of Professor Vasudevan, Head of Department of Neurology, Saveetha University, Chennai and Dr. Balamurali of Ganag Hospital, Coimbatore were also taken, who also concluded to be ‘Cauda Equina Syndrome’, which was an inherent rare complication of the anaesthesia. While administering anaesthesia, no injury, damage or lesion was caused as was confirmed in several MRI scan. The opposite party adopted standard discipline in treatment of the complainant and did not commit any negligence either in administer anaesthesia or in surgery. Medical Certificate dt. 06.11.2014 of Ayurvedic College Hospital, Coimbatore, shows that the complainant was walking with support of walker and his condition was improving. The complaint is liable to be dismissed. 5. The complainant filed Affidavit of Evidence of N.V. Chandramohan and documentary evidence. Along with his Affidavit of Evidence, the complainant filed Discharge Summary of ‘kauvery hospital’ dated 24.01.2015 and Income Tax Return filed on 06.02.2015, and other documents. The opposite party filed Affidavits of Evidence of Dr. N. Amar (Consultant Anaesthesiologist), Dr. Nalla G. Planiswami (Managing Director) and documentary evidence. The opposite party filed Opinions of Head of Department of Anaesthesia at CMC, Vellore dated 02.09.2021, Dr. Karthikeyan Chandrasekaran, Consultant Anaesthetist as Saff Specialist at Ipswich Hospital, Queensland Australia dated 27.09.2021 and Dr. Kamal Kumar, Associate Professor/Consultant Anaesthesiologist at London Health Science, Ontario Canada, Western University dated 27.09.2021. Under the order of this Commission dated 30.10.2019, a report dated 11.01.2020 was submitted by a Medical Board of Government Mohan Kumarmangalam Medical College Hospital, Salem, about condition of the complainant, stating that the complainant was suffering from Type II Diabetes mellitus (Hb A1 C 8.4- fair glycemic control), Systematic Hypertension (Optimal Blood Pressure control), Residual flaccid paraplegia/ cauda–equina syndrome. Non-ambulant–Wheel chair bound. Diabetic Neuropathy. Both the parties filed written synopsis. 6. The counsel for the complainant submitted that the opposite party noted in ‘discharge summary’ that after surgery of ‘total knee replacement’, the complainant suffered from ‘Cauda Equina Syndrome’, due to which, lack of sensation and movement in his legs was caused, as diagnosed on 20.05.2014. The weakness was sensory level up to L2 and motor level up to L1. The tone was reduced and power was 0/5 from thigh downwards. Cerebrospinal Fluid showed inflammatory. As such it is proved that the doctors of the opposite party had committed negligence, while administering anaesthesia. The opposite assured the complainant that after surgery of ‘total knee replacement’ of his left leg, he would be able to walk normally without any pain. But after surgery, the complainant has been paralyzed with his both the legs and suffered acute pain and loss of income. 7. The counsel for the opposite party submitted that ‘Cauda Equina Syndrome’ was an inherent rare complication of the anaesthesia, as per medical literatures. The opposite party has also filed Opinions of Expert Doctors in this respect i.e. Head of Department of Anaesthesia at CMC, Vellore dated 02.09.2021, Dr. Karthikeyan Chandrasekaran, Consultant Anaesthetist as Saff Specialist at Ipswich Hospital, Queensland Australia dated 27.09.2021 and Dr. Kamal Kumar, Consultant Anaesthesiologist at London Health Science, Ontario Canada, Western University dated 27.09.2021. Dr. N. Amar (Consultant Anaesthesiologist) filed his Affidavit of Evidence, stating that he had explained to the patient about the anaesthetic procedure of spinal epidural anaesthesia and nerve block procedure and risk involved in it and obtained prior “informed anaesthetic consent” from the patient. It has been found in various studies that epidural anaesthesia/analgesia improves the post-operative outcome by relieving pain, reducing pulmonary complications, allowing early mobilization and shortening the length of hospital stay as such he had adopted spinal epidural anaesthesia. After anaesthetic and cardiac evaluation, the complainant was prepared for ‘Total Knee Replacement’ on 18.04.2014 under spinal epidural analgesia and nerve block (sciatic and femoral nerve). He followed the procedure of internationally recognised anaesthesia with standard care and used standard anaesthetic drugs, in administering the anaesthesia, both during knee replacement surgery on 18.04.2014 and post the surgery. He denied committing of negligence. The complainant did not cross examine him. In the absence of any rebuttal evidence, there is no reason to doubt upon his affidavit. He relied upon judgment of Supreme Court in Bombay Hospital & Medical Research Centre Vs. Asha Jaiswal, AIR 2022 SC 204. 8. We have considered the arguments of the counsel for the parties and examined the record. The complainant has neither given the instance of negligence nor adduced any evidence of negligence. The complainant relied upon ‘discharge summary’ and argued that as the opposite party itself had noted ‘Cauda Equina Syndrome’ in it, as such inference of negligence has to be drawn. ‘Cauda Equina Syndrome’ is the compression of a collection of nerves roots. Nerves send and receive electrical signals all across the body. When nerves root in the lumbar spine are compressed, cutting of sensation and movement occur, Nerve roots that control the function of the bladder and bowel are especially vulnerable to damage. According to medical literature as published in Medicine (Baltimore), National Library of Medicine dated 11.05.2018, that probability of ‘Cauda Equina Syndrome’, after undergoing single spinal administration of bupivacaine is 0.75%. Explanation for this complication is uncertain but could be due to needle or introducer trauma at the time of insertion or due to neurotoxic properties of bupivacaine. In the absence of any allegation/ evidence, it cannot be held that Dr. N. Amar had committed negligence in administering spinal epidural anaesthesia and nerve block as the chance of effect of neurotoxic properties is also there. Supreme Court in Jacod Mathew Vs. State of Punjab, (2005) 6 SCC 1 and Martin F. DSouza Vs. Mohd. Ishafaq, (2009) 3 SCC 1, held that in order to apply the principle of ‘res ipsa loquitur’ in the circumstances of a particular case, some evidence which, viewed not as a matter of conjecture but of reasonable argument, makes it more probable that there was some negligence, upon the facts as shown and undisputed, than that the occurrence took place without negligence. In the present case, there is chance of effect of neurotoxic properties of medicines as such by applying the principle of ‘res ipsa loquitur’ the opposite party cannot be held for committing negligence. 9. Allegation that the complainant was lured to undergo ‘knee replacement surgery’ by the opposite party has been denied. The opposite party stated that the complainant came to the hospital on 02.04.2014, complaining severe pain and stiffness in the left knee, with swelling, from last 2 months and also informed that he was diabetic and was on intermittent oral hypoglycaemic agents. The complainant was examined as an out-door patient by Dr. A.S. Thennavan, Senior Consultant Orthopaedician. On his pre-operative visit, his random blood sugar was 116 mg, which was normal and he did not have any symptoms of systematic involvement in diabetes. On examination, the doctor found ‘joint bone tenderness with limited range of movement associated with pain’ in left knee. X-rays revealed Grade IV Osteoarthritic changes. There was no distal neurovascular impairment. General condition of the complainant was stable. The doctor counselled the complainant on various treatment options, which included conservative as well as invasive treatment in the form of knee replacement surgery. The pros and cons of both types of treatment were explained to the complainant. The complainant has concealed consultation on 02.04.2014. It is natural that if any patient consults with a doctor, then he would inform about all alternative modes of treatment. There is no allegation regarding negligence committed during treatment, for the period for which the complainant remained in the hospital. O R D E R In view of the aforesaid discussion, the complaint has no merit and is dismissed. |
