Haryana

Karnal

CC/425/2022

Mr. Surat Singh - Complainant(s)

Versus

Shree Hari Hospital - Opp.Party(s)

Raghav Mehta

29 Nov 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                Complaint case No.425 of 2022

                                                Date of instt. 25.07.2022

                                                Date of Decision 29.11.2024

1.     Mr.Surat Singh aged 54 years occupation: Labourer;

2.     Ms.Savita Devi aged 28 years, Occupation: Housewife.

3.     Piyush Sharma aged 9 months (minor) through his mother Ms.Savita Devi;

4.     Dhruv Sharma age 3: years (minor) through his mother Ms.Savita Devi, all the above mentioned residents of Rasulpur Kalan Village, Karnal, Tehsil Karnal, District Haryana, 132001.

                                                                …….Complainants

                                        Versus

1.     Shree Hari Hospital

2.     Dr.Tarun Goyal (owner of Shree Hari Hospital)

3.     Dr.Kanuj Arora (Consultant Anaesthetist at Shree Hari Hospital)

4.     Mr.Keshav Mittal (Compounder at Shree Hari Hospital).

5.     Mr.Ashish (Compounder at Shree Hari Hospital)

6.     Ms.Palwinder (Nurse at Shree Hari Hospital)

All the above address at 31, Ashoka Colony, Opposite Kalpana Chawla Medical College, Karnal, Haryana 132001.

7.     Sikka Save Life Blood Bank.

8.     Mr.J.K.Sikka (owner of Sikka Save Life Blood Bank), address at 16, Ist Floor, Jarnally Colony, Opposite General Hospital, Karnal, Haryana 132001.

                                                        …..Opposite parties

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before      Sh. Jaswant Singh…….…President 

Mrs.Neeru Agarwal.………..Member

                Mrs.Sarvjeet Kaur………….Member

 

Argued by:Shri Raghav Mehta, counsel for complainants.

               Shri G.P.Singh, counsel for the OPs No.1 to 3.

                Op No.4 given up.

                OPs No.5 & 6 exparte VOD 27.09.2022.

                Shri Yogender Kumar Mehla, counsel for OPs No.7

& 8

(Jaswant Singh President)

 

ORDER:

 

                The complainants have filed the present complaint under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that the son of complainant No.1 namely Pankaj (since deceased) aged 27 years old was working as a helper in United Insurance Company. The deceased fell sick on 25.10.2021, in consequences of his sickness on 26.10.2021, the complainant No.1 admitted his son in OP No.1. After conducting multiple preliminary test and examination of the deceased, the deceased was admitted in ICU by OP No.3. At about 01:30 PM, OP No.3 informed the complainant No.1 that the deceased is suffering from Dengue and the platelets count of the deceased is 24,000/mm3 and there is need to conduct a blood transfusion. OP No.3 asked the complainant No.1 to arrange 1 unit of platelets, particularly from OP No.7 and after taking the blood samples gave a chit with the directions to go to OP No.7 to buy 1 unit of platelets. The complainant No.1 rushed and bought 1 unit of platelets from OP No.7 for Rs.11,000/- and received a receipt dated 26.10.2021. The OP No.1 conducted the first blood transfusion on 26.10.2021 subsequently the health condition of deceased was improved as reported in the hospital file by the staff of OP, but in fact the staff of OP No.1 orally informed about the deterioration of health condition of deceased Pankaj. Additionally, the complainant No.1 asked OP No.3 "what is the platelets count of the deceased?" to which OP No.3 did not respond. The complainant No.1 also asked OP No.3 multiple times, that if you are incapable to handle the situation should the complainant No.1 admit the deceased in some other hospital in a metropolitan city to which OP No.3 did not respond.

2.             On 27.10.2021 OP No.3 informed the complainant No.1 that they have to conduct second blood transfusion and pressurized the complainant No.1 to arrange another unit of platelets from OP No.7 and the complainant No.1 immediately rushed to the premises of OP No.7 and it is matter of surprise OP No.7 without matching the blood samples handed over the bag of platelets to the complainant No.1 on receipt of Rs.11,000/-, however the complainant No.1 also insisted to the staff of OP No.7 to at least match the blood sample with the bag of platelets but of no use. The second blood transfusion was conducted on 27.10.2021 and within few seconds of blood transfusion, the deceased complained of chills/rigors with fever, and respiratory discomfort. At the time of the adverse reaction, there was no qualified doctor or specialist present to handle the emergency/critical situation. After these symptoms, the blood transfusion was stopped and OP No.3 asked the complainant No.1 to return the platelets pack to OPs No. 7 & 8. The complainant No.1 acted as per the instructions of OP No.3 and handed over the blood pack to OP No.8. Before conducting the blood transfusion, the staff of OP No.1 failed to rematch the sample of the deceased blood with the platelet unit being transfused and post the adverse reaction on 27.10.2021 the OPs did not check the platelet unit for any kind of contamination, expiry, or mismatch of the blood as per the rules/regulations of National Blood Transfusion Council (NBTC). At the time of above mentioned blood transfusion there was no medical specialist present. Post the second transfusion conducted on 27.10.2021, at about 04:30 PM, the health of deceased started deteriorating and moreover, the complainant No.1 asked that as such medical facilities including the qualified staff and doctors were not present in the ICU to OP No.3, “if you are incapable of treating the deceased, shall I take the deceased to some other hospital” to which OP No.3 did not respond. OP No.3 instructed the complainant No.1 that no one shall visit the deceased in the ICU except nurse and the compounder and after giving the instructions, OP No.3 left the premises of the hospital. It is a negligent act that when OP No.3, left the hospital, no qualified doctor was present in the ICU to tackle the medical emergencies. It is predominant to mention that on 27.10.2021 after 04:30 PM there was no doctor or competent person to tackle the medical emergencies present in the Intensive Care Unit of OP No.1 and this is one of the important norms for operating an Intensive Care Unit laid down by National Accreditation Board for Hospitals and Healthcare Providers.

3.             On 27.10.2021 OPs No.4, 5, and 6 were on night duty in the ICU to take care of the patients, as ICU is a premises meant for the patients of critical condition. On 27.10.2021 at night, Mr.Krishan Kumar (younger brother of complainant No.1), Mr.Aman (nephew of complainant No.1) and the complainant No.1 were present in the premises of OP No.1. The complainant No.1 was standing in front of room of the deceased and observed that the deceased was in immense pain due to which the complainant No.1 asked OP No. 4 "the deceased is yearning in immense pain, why are you not treating the deceased or calling any expert to treat the deceased?" to which OP No.4 responded in an aggressive manner. OP No.4 was intoxicated on duty as the complainant No.1 could smell alcohol on OP No.4 breath and OP No.4 was also unable to talk properly.

4.             On 28.10.2021 at around 12:15 AM, the condition of deceased worsen and after the complainant No.1 saw the deceased yearning in a lot of pain he tried meeting the deceased but OPs No.4 & 5 did not allow the complainant No.1. He was continuously requesting the OP No.4 to conduct the treatment or call a competent doctor to handle the situation but OP No.4 ignored the entire request and continued smoking his cigarettes in the premises of OP No.1. Furthermore, when the complainant No.1 saw that the deceased is facing difficulty in breathing, he again requested OP No.4 and OP No.4 responded violently by again pushing the complainant No.1 and also tried to intimidate the complainant No1. The utter negligence and maltreatment resulted in the death of deceased on 28.10.2021 at around 12:15 AM. The deceased lost his life solely because of not receiving the adequate treatment and absence of a doctor in the Intensive Care Unit of OP No. 1. OPs No.2 and 3 being the highly qualified person are fully aware of the fact that as per the government norms and regulations it is necessary to have a doctor or a medical specialist in the Intensive Care Unit of a Hospital who is capable of handling the situation in case of any emergency and the absence of a qualified person or a medical specialist in the Intensive Care Unit may result to the death of a patient. OP No.6 called OP No.2 and informed him about the death of the deceased. After being informed about the death, OPs No.2 & 3 reached the premises of OP No.1 at around 1:40 AM on 28.10.2021. After the death of the deceased, OP No.4 locked himself in a room and OPs No.2 & 3 called the Police. Further, OPs No.2 & 3 removed the patient who was admitted on the bed beside the bed of deceased and forced the other patients in the ICU to leave the premises of OP No.1. As soon as the police reached, the premises of OP No.1, the complainant No.1 informed the police that OP No.4 is drunk on his duty and police conducted the MLR of OP No.4. The Urine samples of Op No.4 are sent to the Forensics Lab, Madhuban of which the results are awaited. The Post Mortem Examination of the deceased was conducted on 28.10.2021 by Dr.Ashish Verma and Dr.Nikita Bhatnagar at Civil Hospital, Karnal. Complainant No.1 got recorded his statement in respect to the aforesaid incident in the Civil Lines, Police Station, Karnal on 28.10.2021.  OP No.8 is running Sikka Save Life Blood Bank also played a pivotal role which resulted in the death of the son of complainant No.1 because the OP No.7 without matching the blood sample of deceased gave 1 unit of platelets second time to the complainant No.1. OP No.7 has not kept the second bag of platelets which was returned by complainant No.1 on 27.10.2021, which creates a sufficient suspicion that the second bag of platelets was either contaminated, expired one or was not matching with the blood samples. The second bag of platelets was an important piece of evidence that would have helped to determine the reason of reaction. It is appropriate to mention that the aforesaid blood transfusions conducted on 26.10.2021 and 27.10.2021 by OP No.1 and employees of OP No.1 were conducted by an Anaesthesia Consultant and in the absence of a doctor specializing in blood transfusion. In relating to the aforesaid incidents the complainant No.1 had issued a letter to Hon’ble Chief Minister’s office complaining the medical negligence conducted by the OPs. Complainant No.1 also registered a complaint in the office of Superintendent of Police, Karnal on 24.12.2021. In relation to the aforesaid incidents the complainant No.1 had issued a letter to the Hon'ble Home and Health Minister's office complaining of the medical negligence conducted by the OPs.  Complainants declines to accept the Investigation Report issued by Medical Board for Negligence in toto. The deceased was the sole bread earner in the family and the deceased also has two minor children and a wife. Furthermore, the livelihood of the complainants was dependent on the income of the deceased. After the death of the deceased there is no other male member to earn the livelihood for the entire family and the entire family has become hand to mouth and further to this the deceased was hale and hearty person and was working as a helper in United Insurance Company and was getting salary of Rs.3,60,000/- and apart from this deceased was running a dairy business and was earning Rs.20,000/- from the said dairy business. OPs deliberately and knowingly left the patients in the Intensive Care Unit at the mercy of the unqualified individuals that were unable to handle the medical complexities occurred all of a sudden. OPs did not maintain the basic legal parameters to run an Intensive Care Unit in a Hospital knowingly having full knowledge that the patients may die in the absence of the basic requirements needed for the same. OPs actions have caused great deal of financial and mental hardships to the complainants, especially in the time when a Human Life was on the line and needed the help from the OPs the most. OPs actions portray its irresponsible and unprofessional behavior towards their patients for which the OPs shall remain solely liable for their conduct. Complainants tried to contact the competent authorities time and again requesting a stern action against the OPs, however, to the utter dismay of the complainants, they never received a positive response from any of the authorities. All the requests made by the complainants and all the attempts made were in vain. Complainant No.1 issued a Legal Notice through his advocates on 29.04.2022 but the OPs have not replied to the Legal Notice. There is an enormous deficiency in the services provided by the OPs. The complainants had never expected such poor service from such reputed service provider. The OPs actions have resulted into causing an enormous amount of mental agony, financial hardship and inconvenience to the complainants and the behavior perpetrated by the OPs is highly irresponsible and inconsiderate in nature and therefore, the OPs are liable to pay compensation for their misconduct under the provisions of the Consumer Protection Act, 2019. Thus, the OPs committed deficiency in service and unfair trade practice. Hence, prayed for allowing the complaint.

5.             On notice, OPs No.1 to 3 appeared and filed their joint written version raising preliminary with regard to cause of action, no expert opinion has been placed on file, etc. On merits, it is submitted that no negligence has been made by the OPs to the patient while providing the treatment. In this case pertaining to professional negligence, the onus lies heavily on the part of the complainants to prove and establish the factum of negligence and only thereafter, the burden that negligence has not been committed is shifted at the shoulder of the treating doctor. Any reasonable man entering into a profession which requires a particular level of learning to be called a professional of that branch, impliedly assures the person dealing with him that the skill which he professes to possess shall be exercised and exercised with reasonable degree of care and caution. He does not assure his client of the result. A lawyer does not tell his client that the client shall win the case in all circumstances. A physician would not assure the patient of full recovery in every case. A surgeon cannot and does not guarantee that the result of surgery would invariably be beneficial, much less to the extent of 100% for the person operated on. The only assurance which such a professional can give or can be understood to have given by implication is that he is possessed of the requisite skill in that branch of profession which he is practising and while undertaking the performance of the task entrusted to him he would be exercising his skill with reasonable competence. The standard to be applied for judging, whether the person charged has been negligent or not, would be that of an ordinary competent person exercising ordinary skill in that profession. 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 honestly believes he as providing greater chances of success for the patient rather than a procedure involving lesser risk but higher chances of failure. No sensible professional would intentionally commit an act or omission which would result in loss or injury to the patient as the professional reputation of the person is at stake. There is no expert evidence on record to suggest that any negligence was committed by the OPs in the instant case, neither any medical literature is filed by the complainants to establish their case. It was informed by the OP No.3 that the deceased was suffering from Dengue and the platelets count of deceased were towards lower side. Since the platelet count in dengue fever deceases because the blood cells are affected by the virus that causes platelet damage, so blood transfusion is one of the effective treatment to treat the patient suffering from dengue and due to this reason, the complainant No.1 was asked to arrange 1 unit of platelets from blood bank, a however, it is incorrect that the complainant No.1 was asked to bring the one unit of platelets particularly from the OP No.7. It is well in context to mention here that there are 4-5 blood banks situated on Civil Hospital Road, Karnal and the complainant No.1 was asked to bring 1 unit of platelets from one of the said blood banks as per his choice. The OPs are least concerned about the arrangement of unit of platelets by the relatives of patient. Bringing the unit of platelets from the OP No.7 by paying the amount of Rs.11,000/-. The complainant No.1 was being continuously informed about the condition of the patient and was also told to the complainants that if they want to take their patient higher centre, the OPs have no objection to the same. Blood transfusion is one of the effective treatments of dengue and due to this reason, the complainant No.1 was asked to bring another unit of platelets, however, the complainant No.1 was never pressurized to bring the unit of platelets particularly from the OP No.7. It is correct that the patient was shifted to Intensive Care Unit, but it is incorrect that there was no qualified doctor or specialist person to handle the emergency or critical situation. Infact, the OP No.3 was present in the hospital throughout and was taking proper care of the patient. It is incorrect that the staff of the OP No.1 failed to re-match the sample of deceased blood with the platelet unit being transfused and post the adverse reaction on 27.10.2021. It is relevant to mention here that whenever, the need arises for blood transfusion, the blood group of the patient is tested and the blood sample of patient is given to his relative so as to enable the blood bank to give the blood unit as per the said blood sample. The condition of the patient was being monitored continuously by the OP No.3 and throughout the day and night, qualified doctor was present to supervise and treat the patients. The deceased was being given proper treatment and his condition was being properly monitored, but unfortunately, his condition deteriorated and he died. In fact, at around 01:00 AM patient’s condition deteriorated suddenly. Patient was attended by the doctor on duty and ICU staff swiftly and treating consultant was informed about the sudden deterioration of the patient’s condition. In the meanwhile, the attendants of the patient barged into the ICU and started abusing and beating ICU staff badly. MLR in this regard is attached which was conducted by Dr.Ajay Chikara on 28.10.2021 and same proves the assault made by the attendants on ICU staff which grossly hampered the required essential treatment to be given to the deceased. The OPs reached at the spot immediately and found around 10 to 15 attendants inside the ICU creating violence and then police was informed. Feeling compelled, the OPs called the police. It is submitted that the grievance of the complainants were forwarded to Medical Board and the said Medical Board conducted a thorough enquiry into the allegations levelled by the complainants and no medical negligence on the part of OPs was found in treating the patient. Denying all other averments, dismissal of complaint has been prayed for.  

6.             OP No.4 was given up being unnecessary by learned counsel for the complainants by suffering separate statement dated 17.10.2022.

7.             Despite service of notice, none has put in appearance on behalf of OPs No.5 & 6, therefore, they were proceeded against ex-parte vide order dated 27.09.2022.

8.             OPs No.7 & 8 filed their joint written version raising preliminary with regard to maintainability; locus standi; concealment of true and material facts; estoppels; abuse of process of law; cause of action; jurisdiction. On merits, it is submitted that on 26.10.2021, one unit of platelets was processed by the OP No.7 for patient Pankaj qua which the OP No.7 charged an amount of Rs.11000/ vide receipt no. 3558 dated 26.10.2021. On 27.10.2021 complainant No.1 came to the OPs No.7 and 8 for getting one bag of platelets and the OP No.7 provided the same after due matching of the same for which amount an of Rs.11000/- were received vide receipt No.3585 dated 27.10.2021. Said amount is being charged as per the instructions of Health Department of Govt. of India. However, after some time, the complainant No.1 took back said bag at the lab of the OP No.7 for re-cross matching without reaction form of issued by treating hospital but despite of that on the request of the complainant No.1 and for the satisfaction of the complainant No.1, the OPs No.7 and 8 started the process of cross matching the said platelets with the blood sample which took 20-25 minutes and complainant No.1 was asked to wait for some time but he went away from the Lab and thereafter he did not come forward for collecting said bag of platelets. Said bag platelets after re-cross match was found re-compatible. Hence no fault can be attributed on the part of the OPs No.7 and 8. It submitted that the OP No.7 and 8, supplied the label to the hospital mentioned the date of collection and date of expiry that belongs to said bag. As per Drugs Act 1940, platelets bag/sample was preserved for seven days. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

9.             Parties then led their respective evidence.

10.           Learned counsel or the complainants has tendered into evidence affidavit of complainant No.1 Ex.CW1/A, copy of admission form Ex.C1, copy of blood bank receipt Ex.C2, copy of first blood transfusion record Ex.C3, copy of blood bank receipt Ex.C4, copy of second transfusion record Ex.C5, copy of death summary Ex.C6, copy of MLR Ex.C7, copy of PMR Ex.C8, copy of statement dated 28.10.2021 Ex.C9, copy of letter issued to Chief Minister office Ex.C10, copy of complaint receipt dated 21.12.2021 Ex.C11, copy of letter issued Health Minister Ex.C12, copy of letter from DGHS Ex.C13, copy of investigation report Ex.C14, copy of legal notice Ex.C15, copy of RPAD receipts Ex.C16,  copy of statement of Shri Kanuj Arora Ex.C17, copy of statement of Shri J.S.Sikka Ex.C18, copy of statement of Shri Kanuj Arora Ex.C19, copy of statement of J.K.Sikka Ex.C120 Pendrive Ex.C21 and closed the evidence on 04.05.2023 by suffering separate statement.

11.           On the other hand, learned counsel for the OPs No.1 to 3 have tendered into evidence affidavit of Dr.Kanuj Arora Ex.OP1/A, affidavit of Palwinder Kaur Ex.OP2/A, affidavit of Dr.Keshav Mittal Ex.OP3/A and affidavit of Ashish Ex.OP4/A and closed the evidence on 03.04.2024 by suffering separate statement.

12.           Learned counsel for the OPs No.7 & 8 have tendered into evidence affidavit of J.K.Sikka owner of Save Life Blood Ex.7/A, copy of blood requisition form Ex.7/1, copy of donor registration form Ex.7/2, copy of test report Ex.7/3, copy of receipt dated 26.10.2021 Ex.7/4, copy of donor registration form Ex.7/5, copy test report Ex.7/6, copy of blood group report Ex.7/7, copy of payment receipts Ex.7/8 & Ex.7/9, copies of history of donors Ex.7/10 to Ex.7/13, copy of blood issue register Ex.7/14 & 7/15, copy of particular of donor Ex.7/16, copy of recipient register Ex.7/17, copy of particular of donor Ex.7/18, copy of recipient register Ex.7/19, copy of cross matching register Ex.7/20 to Ex.7/22 and closed the evidence on 03.04.2024 by suffering separate statement.

13.           We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

14.           Learned counsel for complainants, while reiterating the contents of the complaint, has vehemently argued that son of complainant No.1 fell sick on 25.10.2021, and admitted in the hospital of OP No.1 on 26.10.2021 at around 11:50 AM. After conducting multiple preliminary test and examination, OP No.3 informed the complainant No.1 that his son is suffering from Dengue. At around 01:30 PM, OP No.3 asked the complainant No.1 to arrange 1 unit of platelets, particularly from OP No.7. The complainant No.1 purchased 1 unit of platelets from OP No.7 for Rs.11,000/-. After first blood transfusion, the condition of deceased was improved. On 27.10.2021, OP No.3 informed the complainant No.1 that they have to conduct second blood transfusion and pressurized the complainant No.1 to arrange another unit of platelets from OP No.7 and the complainant No.1 again arranged another unit of blood and it is matter of surprise OP No.7 without matching the blood samples handed over the bag of platelets to the complainant No.1 on receipt of Rs.11,000/-. At the time of second blood transfusion, no qualified doctor was present, rather the blood transfusion was done by inexperienced staff of the OP No.1. Thereafter, within a few seconds, the deceased complained of chills/rigors with fever, and respiratory discomfort and blood transfusion was stopped and OP No.3. The OPs played a pivotal role which resulted in the death of the son of the complainant because the OP No.7 without matching the blood sample of deceased gave 1 unit of platelets second time to the son of complainant No.1. Both the patients, died due to sole negligence of the OPs. The deceased was the sole bread earner in the family. OPs did not maintain the basic legal parameters to run an Intensive Care Unit in a Hospital knowingly having full knowledge that the patients may die in the absence of the basic requirements needed for the same. Thus, the OPs committed deficiency in service and unfair trade practice and lastly prayed for allowing the complaint.

15.           Per contra, learned counsel for the OPs No.1 to 3, while reiterating the contents of written version, has vehemently argued that patient namely Pankaj was got admitted in the hospital and after conducting required test, he was found suffering from dengue and proper treatment was done by the doctor Kanuj Arora, who is a qualified and experienced doctor. On 26 & 27.10.2021, during the blood transfusion, Dr.Kanuj Arora was present and after due process, blood transfusion was done. There is no expert evidence on record to suggest that any negligence was committed by the Ops, rather a Medical Board for Negligence was constituted by the Civil Surgeon, Karnal and as per report of said Board, no negligence was found during treatment given to the deceased by the OPs and lastly prayed for dismissal of the complaint.

16.           Learned counsel for the OPs No.7 & 8 while reiterating the contents of the written version has vehemently argued that on the demand of complainant No.1, OP No.7 after matching the blood sample of the patient, provided one bag of platelets on 26.10.2021 and another bag on 27.10.2021 and charged Rs.11,000/- each as per the instructions of Health Department of Govt. of India. On 27.10.2021 complainant No.1 came to the OPs alongwith the second platelets bag for re-cross matching without reaction form issued by treating hospital but despite of that, on the request of the complainant No.1, the OPs started the process of cross matching with the blood sample and after re-cross, match was found re-compatible. As per the Drugs Act, 1940, platelets bag/sample was preserved for seven days, hence, no fault can be attributed on the part of the OPs. The second bag of the platelets was not contaminated and expired one and lastly prayed for dismissal of the complaint.

17.           As per the complainants, on 26.10.2021, complainant No.1 admitted his son namely Pankaj (deceased) at Shree Hari Hospital (OP No.1). Dr.Kanuj Arora (OP No.3) diagnosed his son with dengue. OP No.3 and staff of OP No.1 conducted two blood transfusions on 26.10.2021 and 27.10.2021 using platelets sourced from Sikka Save Life Blood Bank (OP No.7). Blood transfusions were carried out, but the second transfusion resulted in a severe adverse reaction due to negligence on the part of the OPs, which lead to death of the patient on 28.10.2021 at 12:15 AM. The complainants  further alleged that the OPs failed to follow the guidelines/standards issued by the NBTC.

18.           During the course of arguments, learned counsel for the complainants placed on file, copy of General Guidelines of Standard for Blood Banks and Blood Transfusion Services issued by National Blood Transfusion Council (NBTC). The said guidelines are very lengthy, thus, we only discuss with the more relevant guidelines while decide the preset complaint.

19.           The deceased was admitted in the hospital of OP No.1 and OP No.3 after conducting provisional admission diagnosis and a final diagnosis declared that the deceased was suffering from dengue fever and apprised the complainants that the deceased required treatment for dengue. As per the notification dated 09.06.2016 issued by the Ministry of Health and Family Welfare, it is mandatory for the medical practitioners to conduct an ELISA Test to confirm a positive diagnosis of Dengue but OPs did not conduct the ELISA test and declared the patient suffering from dengue.

20.           As per clause J.1.0 & J-2.2 of Standards for Blood Banks and Blood Transfusion Services of NBTC, wherever there is a requirement of blood or its components, it is mandatory for the hospitals to issue a Blood Request Form alongwith recipient’s blood samples to the blood banks. A qualified member of the blood bank is required to verify that the information on the sample label matches the details on the Blood Request Form.

21.           As per clause K of Standards for Blood Banks and Blood Transfusion Services of NBTC, blood units to be issued with a blood cross matching report form containing patient details such as first name with surname, age, sex identification number, ward, bed number, ABO and Rh(D) type. The said clauses also specifically states that it is responsibility of blood bank to train the clinical staff and provide necessary form to be used. But there is nothing on file that OPs have followed the above instructions.

22.           As per clause L-2.1 of Standards for Blood Banks and Blood Transfusion Services of NBTC, states that immediately before transfusion, the doctor/transfusionist should verify the identification of the patient, the blood unit, blood group and cross matching report and associated records.

23.           As per clause M of Standards for Blood Banks and Blood Transfusion Services of NBTC, in the event of Blood Transfusion Reaction to further evaluate the reason of reaction and treat the patient accordingly based on the evaluation, the doctors are supposed to do the following steps:

M-3.1.2 a post transfusion properly labelled blood sample, (avoiding haemolysis) should be obtained from the patient and sent to transfusion service along with the blood container and attached transfusion set.

M 3.1.3 The patient’s post reaction serum or plasma should be inspected for evidence of haemolysis, comparing with pre-transfusion sample.

M3.1.4 A direct antiglobulin test should be done on post transfusion specimen and on pre reaction sample for comparison.

M3.2 Based on the evaluation of clinical findings, review of accuracy of records and results of laboratory tests, additional tests should be done as such:

M 3.2.1 Determination of ABO and RH (D) types on pre and post reaction blood sample from the patient and from the blood bag.

M 3.2.2 Repeat tests for unexpected antibodies in donor and recipients’ blood and repeat cross-match using pre and post reaction blood samples of the patient and donor blood from the bag.

M.3.2.4 Examination of post transfusion urine should be carried out for haemoglobin and its metabolites.

M 3.3 If investigators, are suggestive of a haemolytic reaction or bacterial contamination, patient’s physician should be informed immediately.

24.           That as per the procedure outlined above, in the event of transfusion reaction, doctors and nursing staff are obligated to stop the transfusion and send an Adverse Transfusion Reaction Form, alongwith the pre and post transfusion blood samples and blood bag to the blood bank for evaluation.

25.           As per clauses A and O of Standards for Blood Banks and Blood Transfusion Services of NBTC, it is mandatory for blood banks and hospitals to prepare and maintain and Standard Operating Procedure (SOP) with respect to the performing Blood Transfusion Services.

26.           From the perusal of the oral, documentary evidence and from the above guidelines issued by NBTC, we are of the considered view that OPs have not followed the guidelines issued by the NBTC properly.        

27.           It is pertinent to mention here that on 26.10.2021, the son of complainant No.1, namely Pankaj was admitted in Shree Hari Hospital, Karnal (OP No.1) and found suffering from Dengue. One another patient namely Pankaj son of Ram Pal was also admitted on 25.10.2021 with the same disease. The blood group of both the patients were O-positive. On 26.10.2021, after arranging blood platelets from the OPs No.7 & 8, the blood transfusions were carried out by OPs No.1 to 3, to both the patients and no reaction was found. On the instructions of OP No.3, on 27.10.2021, two bags of platelets were again arranged from the OPs No.7 & 8, through the attendants of their patients between 04:00 PM to 05:00 PM. During the blood transfusion, the condition of both the patients became deteriorated due to reactions of the blood platelets. The son of complainant No.1 expired on 28.10.2021 at about 12:15 AM in the hospital of OP No.1.

28.           After the death of patients, Medical Board for Negligence has been constituted by the Civil Surgeon, Karnal. The Board of Doctors after conducting the detailed inquiry, prepared their report Ex.C14. The opinion of Board of Doctors is reproduced as under:-

“Board is of the opinion that patient was treated by Dr.Kanuj Arora (DNB Anesthesia) expert in Medical ICU. Treatment given to the patient as per Indoor file record was optimum regarding diagnosis of the patient. Routinely and in practice before any transfusion, blood group testing and cross match examination is done. However, 10 significant minor blood groups are there and are not done in practice as per the established protocol. These minor blood groups mismatch rarely can cause significant blood transfusion reaction. Adverse blood reaction form was not filled and sent to the Save Life Blood Centre as earliest possible by Shree Hari Hospital, Karnal. It also appears that number of platelphretic procedure done on 26 & 27.10.2021 were far beyond the capacity of the blood centre as per resources and number of staff available and time taken by the procedure to complete. Also record of donors on donor screening form was not proper as even mobile number was not clearly entered. It also appears that aseptic conditions were not followed strictly.

On seeing the record the board is of the opinion that possibility of death by the severe adverse blood transfusion reaction cannot be ruled out in this case. Patient was not seen by medical specialist in course of treatment. Though the exact cause of death cannot be given as report of the post-mortem is awaited. However, possible reason on the basis of our observations are:-

1. Severe transfusion reaction;
2. Aseptic conditions not followed strictly by the blood centre.
3. Mismatch blood transfusion due to human error.

Going through the records of the blood centre and indoor record file of patient Pankaj admitted in Shri Hari Hospital, Karnal rules out any mismatch blood transfusion due to human error as blood group of both the patients were same and SDP was transfused at different time. There is no evidence to suggest any medical negligence regarding treatment.”

 

29.           As per the report of the Medical Board, there is no medical negligence regarding the treatment done by the Hospital, rather the patients were died due to severe transfusion reaction, Aseptic conditions not followed strictly by the blood centre and mismatch blood transfusion due to human error. The Medical Board, has opined that the Blood Centre was negligent. 

30.           The complainants have alleged that on 27.10.2021, after 04:30 PM there was no qualified doctor was present in the ICU and only inexperienced and unqualified staff (OPs No.4 to 6) were present in the ICU. To revert the version of the complainants, the OPs have tendered affidavits of Dr.Kanuj Arora (OP No.3), Palwinder Kaur (OP No.6), Dr.Keshav Mittal (OP No.4) and Ashish (OP No.5) as Ex.OP1/A to Ex.OP4/A respectively. In their affidavits, they have specifically submitted that they were very well present in the hospital of OP No.1 during the treatment of the patient. Hence, from the said affidavits, it is proved that above said deponents were present in the hospital.

31.           The OPs No.7 & 8, have placed on file copy of blood requisition form Ex.7/1, copy of donor registration form Ex.7/2, copy of test report Ex.7/3, copy of receipt dated 26.10.2021 Ex.7/4, copy of donor registration form Ex.7/5, copy test report Ex.7/6, copy of blood group report Ex.7/7, copy of payment receipts Ex.7/8 & Ex.7/9, copies of history of donors Ex.7/10 to Ex.7/13, copy of blood issue register Ex.7/14 & 7/15, copy of particular of donor Ex.7/16, copy of recipient register Ex.7/17, copy of particular of donor Ex.7/18, copy of recipient register Ex.7/19, copy of cross matching register Ex.7/20 to Ex.7/22.

32.           On 26.10.2021, the blood transfusions procedure was carried out on both the patients namely Pankaj by OPs No.3 to 6 and blood was not reacted. On 27.10.2021, again by the said OPs, the blood transfusion procedure was carried out but within 10 to 15 minutes, the blood was reacted. Meaning thereby, there was no negligence/carelessness of the above OPs No.1 to 6, by transfusing the bloods to both the patients. Moreover, the Medical Board has also held that there is no medical negligence regarding treatment.  Hence, in view of the above discussion and report of Medical Board, we are of the considered view that there is no medical negligence on the part of the treated hospital. Hence, the complaint qua the OPs No.1 to 6 deserves to be dismissed.

33.           On perusal of copy of Blood Issue Register Ex.7/15, it reveals that at Unit No.3652, the blood platelets were issued to the complainant No.1 for his son and at Unit No.3650 the blood platelets were issued to the attendant of another patient namely Pankaj son of Ram Pal. As per said Blood Issue Register Ex.7/15, the blood issued to Sunita wife of Pankaj was re-cross match at about 08:00 PM and blood issued to complainant No.1 was re-cross match at 08:30 PM. But in the present case, neither the complainants nor OPs No.1 to 3 have pleaded that after reaction, the blood was sent back to the OPs No.7 & 8 for re-cross matching. When the blood was not sent back for re-cross matching to the OPs No.7 & 8, then how the above OPs have re-crossed the blood unit. It appears that OPs No.7 & 8, have not re-crossed the blood unit and made a entry only in order to fill up the lacuna in the Blood Issue Register Ex.7/15.

34.           As per Drugs Act, 1940, the platelets bag/sample was to be preserved for seven days. When the OPs No.7 & 8 came to know that due to reaction of blood, the patients have been died, if the above OPs were not at fault, then it was their duty to inform the concerned department and re-cross match the blood platelets in the presence of the competent authority and prepared a report, then destroy the blood platelets, but the above OPs, has destroyed the blood platelets without intimating the concerned authority. It appears that the above OPs have made entry in the Blood Issue Register Ex.7/15, with regard to cross-match just to fill up the lacuna.

35.           It has been proved on record that reason behind the death of patients were the reaction of blood and the reaction had occurred due to contaminated blood supplied by the Blood Bank i.e. OPs No.7 & 8. This fact was further proves from the report of District Medical Board for Negligence, Karnal Ex.C14, wherein they opined that number of platelphretic procedure done on 26 & 27.10.2021 were far beyond the capacity of the blood centre as per resources and number of staff available and time taken by the procedure to complete. Also record of donors on donor screening form was not proper as even mobile number was not clearly entered. In the report, it has been specifically opined that there is no evidence to suggest any medical negligence regarding treatment. Since, the OPs No.7 & 8 were not in a capacity to complete the platelphretic procedure due to lack of resources including staff, etc. then there is possibility that the OPs No.7 & 8 have taken the platelets from other Blood Centre/Lab and supplied to the patients without matching the same. Due to mis-match of blood platelets/contaminated blood, the son of complainant No.1 has been died. Moreover, the OPs No.7 & 8, did not rebut opinion of the Board of Doctors by leading documentary evidence. Hence, the act of OPs No.7 & 8 amounts to deficiency in service and unfair trade practice while supplying the contaminated blood units. 

36.           Now, the question arises for consideration is with regard to quantum of compensation to be awarded to the complainants. The complainants have claimed Rs.50,00,000/- as compensation for untimely death of deceased namely Pankaj which is on the higher side. No doubt, the complainants have lost love and affection of his son, husband and father and suffered mental and physical inconvenience and permanent shock. Hence, it would be justified if reasonable amount be awarded to the complainants. In this regard we also found support from the judgment of the Hon’ble Supreme Court of India in case titled as Arun Kumar Manglik Vs. Chirayu Health & Medicare Private Ltd. & Anr. 2019 (3) Apex Court Judgments 230 (S.C), wherein it has been held as under:-

(ii) Consumer Protection Act, 1986, S.12- Medical negligence- Death of non-working spouse- Compensation- In computing compensation payable on death of a home maker spouse who is not employed, Court must bear in mind that contribution is significant and capable of being measured in monetary terms. In the said case, the Hon’ble Supreme Court of India enhanced the compensation to Rs.15 lakhs with 9% interest from Rs.6,00,000/- awarded by the National Consumer Commission, New Delhi.

 

37.           Keeping in view the ratio of law laid down in the above judgment, facts and circumstances of the case and in view of the young age of deceased and other aspects, it would be justified if an amount of Rs.25,00,000/- is awarded to the complainants on account of untimely death of deceased namely Pankaj due to negligence of OPs No. 7 & 8.

38.           In view of our above discussion, we allow the present complaint and direct the OPs no.7 & 8 to pay Rs.25,00,000/- (Rs.Twenty Five lacs only) as compensation to the complainants in equal shares. The amount of the share of minor children i.e. complainants No.3 & 4 shall be deposited in a nationalized bank in the shape of FDRs till they attain the age of majority. This order shall be complied with within a period of 45 days from the date of receipt of copy of this order. It is made clear if the abovesaid amount is not paid by the OPs within stipulated period then this amount will carry interest @ 9% per annum from the date of announcement of order till its realization. The complaint qua OPs No.1 to 6 stands dismissed. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

 

Announced

Dated: 29.11.2024                                                                    

                                                                  President,

                                                    District Consumer Disputes

                                                    Redressal Commission, Karnal.

 

(Neeru Agarwal)        (Sarvjeet Kaur)                 

     Member                     Member