BEFORE THE A.P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION
AT HYDERABAD.
F.A. 455/2008 against C.C. 935/2006, Dist. Forum-II, Hyderabad.
Between:
Nizam Institute of Medial Sciences (NIMS)
Rep. by its Hospital Superintendent
Panjagutta, Hyderabad. *** Appellant/
O.P.
And
1. A. Veera Venkata Rama Rao
S/o. Late Satyanarayana
2. A. Kodanda Rama Rao
S/o. Late Satyanarayana
3. A. Siva Ramakrishna
S/o. Late Satyanarayana
All are R/o. 4071,
Kedar Lanka, Kothapeta (M)
East Godavari Dist. *** Respondent/
Complainant
Counsel for the Appellant: M/s. S. S. Bhutt
Counsel for the Resp: M/s. Sushil Kumar Dubey.
CORAM:
HON’BLE SRI JUSTICE D. APPA RAO, PRESIDENT
&
SMT. M. SHREESHA, MEMBER
THURSDAY, THIS THE SEVENTH DAY OF OCTOBER TWO THOUSAND TEN
Oral Order: (Per Hon’ble Justice D. Appa Rao, President)
***
1) This is an appeal preferred by the opposite party NIMS against the order of the Dist. Forum directing it to pay Rs. 1 lakh towards compensation for medical negligence.
2) The case of the complainants in brief is that they are the sons of Smt. A. Venkata Laxmi. When she was suffering from continuous head-ache she was admitted in M/s. Apex Hospital, Visakapatnam in the month of April, 2006. The doctors after taking X-Ray, brain C.T. scan etc. opined that she was in need of surgery to the brain directed them to take her to the appellant hospital. Accordingly they admitted her on 24.4.2006 by depositing Rs. 10,000/-for taking various tests. Later after conducting various tests they directed them to deposit Rs. 1 lakh for conducting surgery of the brain which they deposited.
On 26.4.2006 brain surgery was conducted and she was kept in ICU. They were not aware of her condition. On 4.5.2006 she was administered some injection and on that she had severe reaction and she developed seizures and restlessness. She got rashes and burning bubbles on her body and face. This was administered by one Dr. Phani Raj. He prescribed costly medicines worth Rs. 4,000/- per day for a period of 10 days. On 13.5.2006 Dr. Phani Raj performed surgery by opening her trachea . She was administered oxygen as she was unable to breathe. Due to wrong diagnosis and administration of medicines she had suffered severely. Since her condition was not improved she was admitted in St. Theresa hospital on 24.5.2006 where she died on 25.5.2006. All this was due to wrong diagnosis and treatment given by the doctors in the appellant hospital and therefore they claimed Rs. 3 lakhs towards compensation, Rs. 1 lakh towards damages for mental agony and Rs. 50,000/- towards expenses incurred by them and costs.
3) The appellant resisted the case. It alleged that the patient was admitted in Neurosurgery department on 24.4.2006 with diagnosis of SAH WFNS grade-I with RT MCA bifurcation aneurysm. She was operated on 26.4.2006. She showed satisfactory improvement till the 7th day of post-operative day. When she developed phenytoin induced Steven-Johnson’s Syndrome (SJS) it was managed. She was under tracheotomy to manage respiratory distress secondary to airway problems in SJS. Eventually she was stabilized and was discharged on 24.5.2006. They directed them to deposit Rs. 10,000/- initially and remaining 75% of expected hospital charges as per hospital rules. It did not include doctor’s fee as they are full time employees. The condition of the patient was explained to the attendants. Written consent was also taken. She was not shifted from ICU to the ward during post operative period in the hospital. When she was brought from Visakapatnam on 24.4.2006 where she was diagnosed that she was suffering from Sub-Arachnoid Haemorrhage (SAH) viz., blood leakage in the brain. For confirmation it has conducted some more tests and came to the conclusion that she was suffering from SAH grade-I with right MCA (Middle Cerebral Artery) bifurcation aneurysm. From day one she was put on Phenytoin tablet. The said drug is being used for effective remedy all over the world. It is the best drug for treating the said ailment without any side effects in most of the cases. There was lot of improvement and stability of health from 24.4.2006 till 4.5.2006. The patient did not complain any un-easiness, restlessness or rashes. However she had developed rashes all over the body on 5.5.2006 due to Phenytoin induced allergy. The medicines that were prescribed before surgery were administered to her regularly in the post-operative period also. She did not complain any rash or un-easiness etc. The patient was under the care of Dr. A. K. Purohit, Head of the Department of Neurosurgery. Dr. Phani Raj is only a trainee and had no power to take decisions for administering the medicines. When she had rashes she was referred to Dermatologist who opined it as SJS. When the drug to control the seizures after operation was given, she developed rashes over her body which is a very rare phenomenon that too after two weeks of such administration. The patient was administered with drugs like Sodium Valproate and Clobazam in place of Phenytoin to reduce rashes. In fact the relatives and the attendants of the patient appreciated the timely action and administration of antidote and saving her life. On 13.5.2006 when she developed severe breathlessness, in order to save her life, Dr. Suresh performed tracheotomy by opening the trachea and inserting a tracheotomy tube for the purpose of relieving respiratory distress. There upon her condition had been improved. The patient was obese. There would be several complications post-operatively in cases of such patients. She might have died due to heart attack in St. Theresa Hospital, Kukatpally, Hyderabad later for which they were not liable. Neither the diagnosis nor the treatment was wrong. The very same diagnosis that was made by the hospital authorities at Viskapatnam was confirmed by conducting various tests. For the notice issued by the complainants they gave correctly reply. The patient was discharged in good health. The claim of compensation was unjust, highly excessive and therefore prayed for dismissal of the complaint with exemplary costs.
4) The complainants in proof of their case filed Exs. A1 to A10 while the appellant hospital filed Exs. B1 to BB7.
5) The Dist. Forum after considering the evidence placed on record opined that there was negligence on the part of doctors of appellant hospital in administering Phenytoin causing severe drug reaction consequently resulting the death of patient. It also opined that the appellant hospital discharged the patient irresponsibly when she was not recovered from the drug reaction. Therefore it directed the appellant to pay Rs. 1 lakh towards compensation together with costs of Rs. 5,000/-.
6) Aggrieved by the said decision, the appellant hospital preferred the appeal contending that the Dist. Forum did not appreciate either facts or law in correct perspective. The complainant did not examine themselves any expert to prove any negligence on the part of their doctors to fasten liability on it. They have not even cross-examined their doctors. They did not even file the medical literature to prove their case. There was no nexus between the cause of death and the alleged drug reaction. The patient died in a different hospital after her discharge from their hospital. The complainants failed to prove that there was negligence on their part. Therefore it prayed that the order of the Dist. Forum be set-aside and consequently dismiss the complaint.
7) The point that arises for consideration is whether the order of the Dist. Forum is vitiated by mis-appreciation of fact or law?
8) It is an undisputed fact that the deceased late A. Venkata Laxmi, mother of the complainants, after taking treatment in the month of April, 2006 in M/s. Apex Hospital, Visakapatnam for SAH WFNS grade-I with RT MCA bifurcation aneurysm she was admitted in appellant NIMS hospital at Hyderabad on 24.4.2006. After taking consent from the complainants, and after conducting various tests, like C.T. Scan, brain scan, X-Ray etc. confirmed the diagnosis and conducted brain surgery on 26.4.2006. She was administered Phenytoin in Apex Hospital, Visakapatnam, and the same was continued among other drugs.
When Phenytoin was continued she had developed seizures and rashes on 5.5.2006 and on that the said drug was discontinued. She was referred to Dermatologist when she developed rashes. On 13.5.2006 when she developed breathlessness and Dr. Suresh performed tracheotomy. Obviously the procedure was uneventful and the patient improved from respiratory distress. Finally she was discharged on 24.5.2006. Later she was admitted in St. Theresa Hospital, Hyderabad on 25.5.2006 where she died due to ‘cardio respiratory arrest’ evidenced under Ex. A10 certificate issued by St. Theresa’s hospital, Hyderabad. The complainants allege that the diagnosis as well as the treatment were inaccurate and she could not have developed seizures followed by rashes but for administering wrong medicine Phenytoin. They were un-necessarily made to pay for surgery and treatment etc.
9) At the outset, we may state that for the reasons best known the complainants did alone file their affidavit evidence to state that administration of Phenytoin was incorrect though the patient was suffering from SAH WFNS grade-I with RT MCA bifurcation aneurysm for which same medicine was administered in Apex Hospital, Visakapatnam. She did not get any adverse reaction. Importantly the complainants did not examine any doctor/expert to state that the diagnosis, surgery and post operative treatment were not in correct lines. Obviously the complainants had assumed that the surgery and the treatment given by the appellant hospital was incorrect in view of the fact that she had developed seizures as well as rashes. When the complainants had issued legal notice claiming compensation the appellant gave reply in Ex. A8 mentioning:
“the rashes were first seen on 5.5.2006 which were erthymatous, oedematous and bullae on face, ears, and lips. Appropriate dermatologist consultation was taken and the condition was opined as drug induced dermatitis probably due to Phenytoin. This drug is routinely used for many patients. It is a rare phenomenon and extremely difficult to say it may develop this kind of drug reaction.”
Phenytoin is a known cause to SJS (reference Harision’s Principles of Medicine-Vol-I, Edition 15; meylers – side effects of drugs – 12th edition) and SJS has a mortality rate of 15% at the best centres in United States. As the cause of SJS in this case is phenytoin, symptomatic treatment was extended to the patient and the drug was withdrawn as per the rashes progressively decreased and patient made symptomatic recovery, respiration was normalized and though the patient was hefty and bedridden with desquamating rashes all over, she did not develop any bedsores or features suggestive of infection during her stay of 1 month in the hospital which is representative of the excellent care extended to the patient. If the doctor is negligent in patient care, he will not like to shift the patient under any other doctor care. Because he would not know about his negligence. In this case the doctor have never insisted to shift the patient to other hospital. The attendants were explained about the danger of nosocomial infection in such (having many desquamating rashes all over the body and tracheotomy) cases. The infection can result in septicaemia and can endanger the life.
The treatment was never stopped and according to the hospital documents all medications were administered until the time of taking the patient away from the hospital.”
When they found that there was adverse drug reaction to the drug Phenytoin which was diagnosed by a qualified Dermatologist, immediately according to them:
“ The patient was appropriately diagnosed as soon as she reached the hospital and operated successfully. The drug induced problem was also diagnosed at the earliest and most appropriate treatment and care was given keeping her in ICU till she improved and remained stable in her health condition. At no point of time, the treating doctors have deviated from the standards of procedure in managing the patient. There was no deficiency of service on the part of the doctors who treated the patient. “
10) The Bolam’s test has been approved by the Hon’ble Supreme Court. After a review of various authorities Bingham L.J. summarised the Bolam test in the following words:
“that a professional man should command corpus of knowledge which forms part of the professional equipment of the ordinary member of his profession. He should not lag behind other ordinary assiduous and intelligent members of his profession in knowledge of new advances, discoveries and development in his field. He should have such awareness as an ordinary competent practitioner would have of the deficiencies in his knowledge and the limitations on his skill. He should be alert to the hazards and risks in any professional task he undertakes to the extent that other ordinary competent members of his profession would be alert. He must bring to any professional task he undertakes no less expertise, skill and care than other ordinary competent members of his profession would bring, but need bring no more. The standard is that of the reasonable average. The law does not require of a professional man that he be a paragon combining the qualities of polymatch and prophet.
"In the realm of diagnosis and treatment there is ample scope for genuine difference of opinion and one man clearly is not negligent merely because his conclusion differs from that of other professional men.... The true test for establishing negligence in diagnosis or treatment on the part of a doctor is whether he has been proved to be guilty of such failure as no doctor of ordinary skill would be guilty of if acting with ordinary care...."
The higher the acuteness in an emergency and the higher the complication, the 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 has to choose the lesser evil. The doctor 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 but a doctor cannot be penalized if he adopts the former procedure, even if it results in a failure. The usual practice prevalent nowadays is to obtain the consent of the patient or of the person in-charge of the patient if the patient is not in a position to give consent before adopting a given procedure.
Simply because a patient has not favourably responded to a treatment given by a doctor or a surgery has failed, the doctor cannot be held straightway liable for medical negligence by applying the doctrine of res ipsa loquitur No sensible professional would intentionally commit an act or omission which would result in harm or injury to the patient since the professional reputation of the professional would be at stake. A single failure may cost him dear in his lapse.”
11) The complainants as we have earlier mentioned made several allegations against Dr. Phani Raj and Dr. Suresh who according to them treated the patient without requisite qualifications. This was denied by the appellant hospital authorities in their version. They have categorically stated that she was treated by Dr. A. K. Purohit, Head, Department of Neurosurgery. A perusal of case sheet would undoubtedly show that she was under the care of Dr. A. K. Purohit, Head, Department of Neurosurgery. The complainants could not let in any evidence that Dr. Phani Raj, who does not have requisite qualifications attended on her. It is not as though they did not attend on her. Undoubtedly they might have attended on the patient but it was under the directions of his Head Dr. A. K. Purohit.
12) At the cost of repetition, we may state that there is no evidence to show that prescribing Phenytoin was wrong and that the treatment that was given to her went in incorrect lines. It was not substantiated by examining doctors or by referring to any authoritative medical texts. The complainants had assumed that the treatment given by the appellant hospital was wrong solely on the ground that their mother had developed seizures and drug reaction which was treated by the doctors. The complainants could have examined the doctors at St. Theresa’s Hospital where she was admitted after her discharge from the appellant hospital to prove that wrong drugs were administered to her. When medical negligence was not proved the question of awarding compensation will not arise. We have carefully perused the entire record and we are of the opinion that the appellant was not at fault. Therefore the order of the Dist. Forum is un-sustainable.
13) In the result the appeal is allowed setting aside the order of the Dist. Forum. Consequently the complaint is dismissed. However, in the circumstances of the case, no costs.
1) _______________________________
PRESIDENT
2) ________________________________
MEMBER
Dt. 07. 10. 2010.
*pnr
“UP LOAD – O.K.”
