Appeared at the time of arguments

For the Appellant                      :        Mr. Deepak Aggarwal, Advocate

For the Respondents                 :        Mr. Sudarshan Rajan, Advocate &

Mr. Hitain Bajaj, Advocate

for R-1 to 3, 6, 8, 10 & 13

None for Ors.

Pronounced on: 17^th April 2023

ORDER

Dr. S. M. KANTIKAR, PRESIDING MEMBER

1.       The Appellant (Complainant)  has filed the instant Appeal under section 19 of the Consumer Protection Act, 1986 (in short “the Act”), against the Order dated 06.09.2013 passed by the State Consumer Disputes Redressal Commission, U.T. Chandigarh (hereinafter referred to as the “State Commission”) in Consumer Complaint No. 01 of 2013, wherein the State Commission, dismissed her Complaint.

2.       For the convenience, the parties are being referred to, in the instant Appeal, as position held in Consumer Complaint before the State Commission.

3.       Brief facts relevant to dispose of this appeal are that Mr. Anil Kumar (46 years) since deceased (hereinafter to be referred as the ‘Patient’) was taken to the Emergency Medical OPD (EMOPD) in the PGIMER (OP-1) Hospital on 03.03.2011 morning. It was alleged that ECG confirmed Myocardial Ischemia evolving to Myocardial Infarction, but the doctors have not treated such critical illness. It was further alleged that due to a strike of the hospital staff, the medical services were halted on that day. The patient was not monitored properly for vital signs and not provided nebulization or oxygen. It was further alleged that injection ‘Azithromycin’ was given to the patient without a test dose, it resulted in anaphylactic reaction, it was not treated correctly and condition of patient further deteriorated. The patient ultimately died at around 4.30pm on the same day. The Post Mortem was conducted and the CFL reported the patient died due to acute MI. The immediate cause of death given was Cardiogenic Shock. Being aggrieved, the Complainant filed the Consumer Complaint No. 1/2013 before the State Commission, UT Chandigarh seeking Rs.42 lakhs as compensation.

4.  The OPs No. 1 and 3 to 13 have filed their joint written version and denied negligence during the treatment. It was submitted that during Dec 2010 to Jan 2011, the patient was hospitalised multiple times for his severe heart and chronic lung disease.  On 03.03.2011, he was brought to the Emergency OPD (EMOPD) of PGIMER, Dr. Jayanta Samanta (OP-3) attended the emergency and started on oxygen and nebulization therapy. Injection hydrocortisone was given to him to take care of acute exacerbation of COPD and life-threatening hypoxia. Diuretics were given for underlying chronic cardiac failure. Patient showed irregular fast heart rate (atrial fibrillation with fast ventricular rate).There was no evidence of acute retrosternal chest pain and ECG did not show signs of MI. 

5.       To take care of acute bacterial infection, IV Azithromycin was started at 11.30 am. It was given as IV infusion 100 ml over 20-30 minutes.  It was denied that the said injection was given in bolus and in great hurry. As the patient was receiving injection Hydrocortisone (steroids) it would take care anaphylaxis if occurs.  The condition of patient deteriorated because of atrial fibrillation with fast ventricular rate. It was documented by Dr. Kiran, Senior Resident of Cardiology. Therefore, immediate resuscitative measures were taken by OP-3  and Dr. Kiran who were present at the bedside of the patient at all times. It was suspected as pulmonary edema, status asthmaticus /acute exacerbation of COPD, it was treated with injection Lasix and hydrocortisone, including oxygen and nebulization therapy.   

6.        The State Commission based on the averments dismissed the Complaint of the Complainant with the following observation:-

“…26. In the final analysis, it is held that  Opposite Parties 1 and 3 to 13, exercised an ordinary degree of skill and competence in treating and taking care of Anil Kumar (now deceased), in the best possible manner, during the period he remained admitted in the PGIMER. Thus, the Opposite Parties were not at all guilty of Medical negligence, in treating Anil Kumar (now Deceased). There was, thus, no deficiency, in rendering service, on the part of the Opposite Parties.”

7.       Being aggrieved by the impugned Order, the Complainant / Appellant has filed the instant Appeal. 

8.       We have heard the learned Counsel for both the sides and perused the material on record. They have reiterated the facts and the evidences which were filed before the State Commission.

9.       The learned counsel for complainant argued that the patient had history of heart disease since the year 2009, but due to sheer negligence of treating doctors at PGI, the patient died on the same day.  The doctors failed to treat MI but they have treated for Cardiomyopathy. The ECG with ST segment depression usually reflects a severe form of impaired coronary blood flow.  Based on medical literature, he argued that Aspirin 150-300 mg should be given which will reduce mortality by 20% including beta blockers including Metaprlol and also glyceryl trinitrate should be given and possibly ACE inhibitors. Further, if a person would have been allergic to Aspirin in the said eventuality Clopidogrel (Plavix 75 mg) daily should be given. Categorisation of M.I. was not done firstly STEMI (S.T. elevation M.I.) and secondly NSTEMI (Non S.T. elevation M.I.). The proper treatment would be PCI with Angioplasty and stenting, clot busting medicines and GABG (coronary artery bypass graft). Further even as per heart attack treatment guidelines 2013, the treatment includes beta blockers, nitro-glycerine and morphine.  

10.     During the argument, the learned counsel for OPs reiterated their evidence and the details of emergency treatment given to the   patient. He submitted that the complainant has not led any expert evidence to establish the deviation from the duty of care or wrong treatment.   He submitted that the Director of PGIMS instituted an enquiry and the Enquiry committee held that the patient was duly attendant and was given treatment to the best of the ability of the attending doctors. The treatment of the patient was un-interrupted and there was no impact of strike / agitation.

11.  We gave our thoughtful consideration to the arguments on both the sides. Perused the medical record, inter-alia, the order of the State Commission. It is pertinent to note that, the patient was known case of severe heart disease with chronic lung disease. He was hospitalised for several times during the month of December 2010/January 2011. On 03.03.2011, morning the patient was brought to EMOPD and was immediately attended to by Dr. Jayant Samanta (OP-3) and started the treatment Oxygen and nebulisation therapy (salbutamol every 10 min.) and Inj. Hydrocortisone.   Diuretics were given in view of the underlying chronic cardiac failure to avoid deterioration. He was treated with proper drugs like Digoxin 0.25 mg., Warf 2 mg, Cordarone 200 mg, Carca 12.5 mg and 6.25 mg. He was also prescribed Lasix 40 mg, Hydrocort 100 mg, Pan 40 mg, Azu 500 mg and Dobutamine 500 mg.

12.     From the standard books on Cardiology due to dilated cardiomyopathy, patient suffers severe left ventricular failure which could have been treated with oxygen and diuretics. In a diagnosed case of dilated cardiomyopathy, if the patient is in shock, the circulation to all vital organs, including heart, kidney, and brain was compromised, which further enhance the development of cardiac arrhythmias, like atrial fibrillation with fast ventricular rate. Therefore, such patients before death exhibited evidence of ischemic damage to these vital organs, clinically or on pathology.

13.     The worsening in the instant patient could have been due to acute exacerbation of COPD, infective complication, or due to irregular, fast heart rate (atrial fibrillation with fast ventricular rate). In absence of acute retro-sternal chest pain and no ECG evidence of my cardiac ischemia/infraction a clinical diagnosis of acute myocardial infraction is difficult. The immediate cause of death in this patient was   cardiogenic shock due to  damaged heart due to dilated cardiomyopathy with left ventricular systolic dysfunction (ejection fraction = 22%).  

14.     We have gone through the standard books on Cardiology.

15.       In the instant case, it is evident that at PGIMER, the doctors have given all standard of care when he was brought to the emergency (EMOPD) on 03.03.2011. Proper medication, Oxygen supply, care for COPD and hypoxia was taken.  For CCF proper diuretics were given. It was the case of CCF secondary to severe left ventricular failure due to dilated cardiomyopathy. In absence of acute retrosternal chest pain and no ECG evidence of myocardial ischemia /infraction a clinical diagnosis of acute MI was difficult. Admittedly, on 03.03.2011, there was an altercation between some other patient’s attendants with the staff nurse OP-8 and OP-9, the strike has no impact on the emergency services. In our view, Inj. Azithromycin was prescribed for acute bacterial infection. It was given in diluted infusion, not in bolus. The chances of anaphylaxis with Inj. Azithromycin were remote in the instant case.  The patient was investigated properly and appropriate medicines in appropriate dosage were given with regard to the heart disease. We agree with the medical opinion of Dr. Ashish Bhalla, Additional Professor, Department of Internal Medicine, PGIMER. The Committee of expert doctors at PGI held that it was correct line of treatment for heart disease.  We do not find any impact on patient care due to strike.

16.     We would like to rely upon the law laid down by Hon’ble Supreme Court on medical negligence. Recently, in Dr. Harish Kumar Khurana v. Joginder Singh & Others[1] held that hospital and the doctors are required to exercise sufficient care in treating the patient in all circumstances. However, in an unfortunate case, death may occur. It is necessary that sufficient material or medical evidence should be available before the adjudicating authority to arrive at the conclusion that death is due to medical negligence. Every injury or death is not necessarily a medical negligence and the treating doctor shall not be held liable. In the landmark judgment in Jacob Mathew’s case^[2], it was held as under:

“When  a  patient  dies  or  suffers  some  mishap,  there  is  a  tendency to blame the doctor for  this.  Things have gone wrong and, therefore, somebody must be punished for it. However, it is well known that even the best professionals, what to say of the average professional, sometimes have failures. A lawyer cannot win every case  in  his  professional  career but surely  he  cannot be  penalized for  losing  a  case  provided  he appeared in it and made his submissions.”

17.      In our view, the Appellant (Complainant) failed to prove her case, not placed any cogent evidence. This view dovetails from the judgment of Hon’ble Supreme Court in Devarakonda Suryasesha Mani v Care Hospital, Institute of medical Sciences^[3], wherein it was held as below:

“..2. Unless the appellants are able to establish before this Court any specific course of conduct suggesting a lack of due medical attention and care, it would not be possible for the Court to second-guess the medical judgment of the doctors on the line of medical treatment which was administered to the spouse of the first appellant. In the absence of any such material disclosing medical negligence, we find no justification to form a view at variance with the view which was taken by the NCDRC.

“Every death in an institutionalized environment of a hospital does not necessarily amount to medical negligence on a hypothetical assumption of lack of due medical care.”

18.     To conclude, based on afore discussion, relying upon the medical record, standard texts and the precedents of Hon’ble Apex Court, medical negligence is not attributable to the PGIMER and the doctors. The Order of State Commission is upheld and the instant First Appeal is dismissed.