DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
(CENTRAL) ISBT KASHMERE GATE DELHI
CC No. 253/2008
No. DF/ Central/ Date
1. Dr. G.S. Malik S/o Late Sh. J.S. Malik
2. Smt. Nirmala Malik W/o Dr. G.S. Malik
Both R/o 6/12 Andrews Ganj, New Delhi
.....COMPLAINANT
VERSUS
1. Sir Ganga Ram Hospital
Rajender Nagar, New Delhi
2. Dr. Vinod Malik
Head Deptt. Of Surgery, Sir Ganga Ram Hospital,
Rajinder Nagar, New Delhi
3. Dr. S. Nandi
Head Deptt. of Surgical Gastroenteroloy,
Sir Ganga Ram Hospital, Rajendra Nagar,
New Delhi
4. Dr. Deep Goyal
Sir Ganga Ram Hospital,
Rajender Nagar, New Delhi
…..OPPOSITE PARTY
Ms. Rekha Rani President
Sh. Vikram Kumar Dabas, Member Mrs. Manju Bala Sharma, Member
ORDER Date: . .2018
Sh. Vikram Kumar Dabas
The complainants have filed the present complaint alleging medical negligence on the part of the OPs in treating their son namely Ravi Malik aged 32 years. Brief facts alleged in the complaint are as under:
On 3/01/2006, the said Ravi Malik suffered stomachache and was admitted to OP 1 Hospital where he was administered Laprotomy which revealed that he had suffered Perforation. He was again admitted to the Hospital on 20/05/2006 as the pain had not subsided and was operated upon for partial gastrectomy with Billorth II reconstruction. He was discharged on 21/04/2006. It is alleged that he had developed wound infection with wound dehiscence with ascetic leakage gradually decreasing. It is alleged that aforesaid Operation was done on the basis of report of OP1 Hospital that the patient was suffering from adenocarcinoma which is a malignant epithelial tumour arising from the glandular structures. It is further alleged that this Operation is usually performed for stomach cancer and upper third or half of the stomach is joined to the douodenum. The Operation is usually carried out in severe cases of peptic ulcers. It is alleged that after the said Operation Ravi Malik started loosing weight and his capacity to take food was drastically reduced. After discharge from the Hospital of OP 1 he was treated at AIIMS where he was detected negative for malignancy. The earlier slides on the basis of which adenocarcinoma was detected were examined at AIIMS which also showed no evidence of malignancy. After the Operation at OP 1 Hospital the complainants had approached OP 3 for knowing the exact cause of problem. OP 3 did not reveal anything and only stated that the patient would require chemotherapy which could be done after some recovery. It is alleged that after 06-07 days of the Operation one of the junior doctor attached to Dr. Nandi had told complainant no. 1 that his son was not suffering from adenocarcinoma but requested not to quote his name. It is also alleged that Dr. Nandi also refused to perform chemotherapy saying that the same was not required as the patient was not suffering from malignancy. It is alleged that Ravi Malik was not suffering from adenocarcinoma or any kind of malignancy for which gastrectomy or even partial gastrectomy was required. It is alleged that OP 1 Hospital had wrongly diagnosed Mr. Ravi Malik as a patient of cancer. The complainants have therefore filed this complaint with the following prayers :
- Direct the respondents to reimburse the applicants an amount of Rs. 4,09,241.62 paise toward the expenses incurred on the treatment of the deceased Ravi Malik.
- Direct the respondents to pay the applicants Rs. 10,00,000/- for mental tension, pain and agony suffered by them during the treatment of their son.
- Further direct the respondents to pay Rs. 10,00,000/- to the applicants for loss of their son at their old age.
- Direct the respondents to pay Rs. 10,00,000/- to the applicants as damages/compensation for their gross negligence resulting in the death of Mr. Ravi Malik.
- Direct the respondents to pay Rs. 10,00,000/- to the applicants as exemplary/punitive cost.
- And to award the applicants cost of litigation.
The complaint was contested by OP1. A written statement was filed wherein preliminary objections were taken that this complaint is not maintainable as the
Complainants have not approached this Forum with clean hands and have suppressed material facts. It was claimed that the averments made in the complaint are false, frivolous, vixicious and baseless and provide no cause of action in favour of the complainants and against the OPs. The OPs contested the case on merits. They admitted that Ravi Malik had been admitted to the Hospital on 03/ 01/2006 with the complaint of severe stomachache. It is stated that he was a known case of peptic ulcer and an alcoholic. The diagnosis of gastric perforation was made through diagnostic laproscopy. It would be relevant to extract para 3, 5, 6 & 7 to 9 of the written statement which gives an insight into the treatment meted out to the patient in OP1 Hospital.
Para 3. It is submitted that Sh.Ravi Malik came to the emergency department of Sir Ganga Ram Hospital on 03.01.2006 with a complaint of severe stomach ache. The patient was a known case of peptic ulcer and a known alcoholic. The diagnosis of gastric perforation was made through the diagnostic laparoscopy. A lot of pus was found, it was removed and perforation was closed with the help of stitches and thus, life of the patient was saved at that time. The patient made a gradual recovery from operation. He remained in the hospital for 17 days. He was discharged when he was restored to his normal condition. He was ambulatory and was eating soft and normal diet. He was advised to undergo upper GI Endoscopy to rule out any pre-disposing condition in the stomach which could have been responsible for perforation of stomach in the first place. The patient was, therefore, referred for further treatment to the Department of Gastroenterology Surgery for further treatment. The patient was seen by the highly qualified experienced doctors and reputed team of Gastroenterology Department who conducted an Endoscopic Biopsy, CT Scan which was suggestive of malignant ulcer. Hence, it was decided to perform partial gastrectomy on the basis of Endoscopic Biopsy which was positive for malignancy and CT Scan which showed a thickened stomach and stranding into adjacent Omentum with Multiple Lymph Nodes. At the time of Operation, the ulcerative growth 2x2 cms was found on the lesser curvature of the stomach and there was large nodes and on the basis of bare eye vision at the time of operation and also the condition of the patient was suggestive to malignancy. Consequently, partial gastrectomy was done on 26.3.2006 and the excised specimen was sent for subsequent histology report which did not confirm malignancy and the patient was therefore not advised to undergo chemo-therapy which had been prescribed earlier. The patient was discharged from Sir Ganga Ram Hospital in a stable condition with an advice to follow-up treatment. The diagnosis and treatment provided to the patient was strictly as per the standard medical practice and there was absolutely no carelessness, irresponsibility or negligence in services on part of the Respondents towards the patient. lt is relevant to submit here that the patient unfortunately died i.e; after eighteen months after the operation done by the Respondents on 16.10.2007 at All India lnstitute of Medical Sciences and not in the hospital of answering respondents. Neither he was being treated by the doctors of answering respondents at the time of his death and as per the documents submitted by the Complainants along with the complaint, it is amply clear that the doctors at All India Institute of Medical Sciences had noted that the patient was a chronic alcoholic. He was suffering from a number of diseases like crohn’s disease, which is a very rare disease, intestinal tuberculosis, which is also very serious disease, anemia etc., so the allegations that his death was caused due to negligence on part of the Respondents are totally false, vexatious and malicious in the nature. The complainant may, however, be put to strict proof thereof.
Para 5. That the contents of Para No.5 are admitted to the extent that Ravi Malik suffered from stomach ache on 03.01.2006 and was hospitalized in Sir Ganga Ram Hospital. It is denied that he was administered laparotomy, as alleged. In fact, only diagnostic laproscopy and subsequent repair of perforation was done which revealed perforation and the perforation was closed with the help of stitches laproscopically and the patient recovered and was discharged in a stable condition and was called for follow-up treatment with the Gastroenterology Department to know the cause of perforation.
Para 6. That the contents of Para No. 6 are totally misconceived and baseless and an attempt to mislead this Hon’ble Forum by making twisted and false averments. It is submitted that because of above operation, so far as perforation of stomach is concerned, it was healed and this particular operation was successful. The pain that which the patient was apparently suffering from was due to the ulcer with which he was suffering and which was diagnosed later by Gastroenterology Department with the help of Endoscopy. When the Endoscopy Biospy confirmed the existence of a cancerous ulcer and CT scan also confirmed it, patient was referred to GI Surgeon then partial gastrectomy was performed. It is relevant to submit here that the treatment for ulcer, which is not healing whether it is malignant or not is same i.e; partial gastrectomy. Therefore the averment that gastrectomy was not required to be done, is totally false. It is denied that the patient died because of gastrectomy when it is very much proved from the record that he unfortunately died because of multiple and serious diseases with which he was suffering from and that too after an interval of about eighteen months after he was discharged by the respondents hospital. It is an admitted fact on record that he had died at All India Institute of Medical Sciences on 16.10.2007 whereas he was last discharge by the respondents hospital on 21.04.2006. It is denied that the patient developed wound infection and wound dehiscence with ascetic leakage, as has been wrongly alleged. The complainant may, however, be put to strict proof thereof.
Para 7 – 9. The contents of paras No.7 to 9 are totally wrong and denied. It is submitted that the operation of partial gastrectomy was done to cure 2x2 cms. large hard ulcer and the treatment has to be same whether it was malignant or not. It is submitted that although the Endoscopic Biospy report as well as CT Scan and also bare eye vision were suggestive of malignancy but subsequent histology report on the excised specimen did not confirm malignancy. The patient was advised against chemotherapy. In any case, the treatment was same and is the standard and approved medical procedure. It is denied that partial gastrectomy is usually performed for stomach cancer only as per the standard medical literature (As given in the Oxford Textbook of Surgery. Vol.l and Baily and Love's Short Practices of Surgery which are the basic textbooks). It is clear that gastrectomy is also prescribed for treatment of gastric ulceration. The relevant portions of the textbooks which fully supports and approves the action of the answering respondents are annexed herewith as ‘Annexure R-1'.
It is denied that Ravi Malik, the patient suffering from drastic weight loss was due to the above said operation when it is duly recorded that he was a known chronic alcoholic and drug addict.
The OPs have claimed that both the surgeries done were successful in treating the patient & improving his condition. They have claimed that the diagnosis & treatment done on the patient were perfectly as per the standard & approved medical procedure. They have also stated that initially the biopsy report, CT scan and visual inspection were suggestive of malignancy but the histology of the excised operation revealed that there was no malignancy which is why chemotherapy was not administered to the patient. It was denied that gastrectomy was not required. It is stated that the treatment of enlarged 2x2 cm ulcer was partial gastrectomy especially after it has perforated & had not healed during the follow up. It had denied that the patient had died of gastractomy or that he had suffered loss of weight or appetite due to the said procedure. It was stated that the patient was suffering from a number of other complications & serious diseases like ch. Alcoholism and drug addiction. The OPs have denied any medical negligence on their part and have prayed that the complaint be dismissed.
The complainants have filed a Rejoinder wherein they have reiterated the averments made in the complaint and have controverted with and denied those made in the written statement.
We have heard arguments advanced at the bar and have perused the record. On behalf of the complainants an affidavit was filed by Complainant No. 1 wherein he has supported the contents of the complaint.
It is pertinent to point out that the matter was referred to the MS LNJP Hospital (Lok Nayak Hospital) for expert opinion. The said Hospital had constituted a board of 4 doctors namely Dr. Gaurav Pradhan (Prof. Radiology MAMC & Lok Nayak Hospital Delhi), Dr. B.C. Sharma (Prof GE, GBP Hospital Delhi), Dr. Vinay Kumar (Director Prof. MAMC Delhi) and Dr. Anil Aggarwal (Prof. & Head GI Surgery GBP Hospital). The board had given its expert opinion dated 31/10/2012 which reads as under :
The committee went through the details of the case & the records provided. Patient named Mr. Ravi Malik aged 3l years, male presented to SGRH
(Ganga Ram Hospital) with features of peritonitis. On laparoscopy,
he had gastric perforation which was closed. While investigating
patient for the cause of gastric perforation, endoscopy was done.
Endoscopy revealed 2x2 cm ulcer in the stomach and biopsy of which showed evidence of adenocarcinoma. CT abdomen also showed features suggestive of malignancy. In view of endoscopy, biopsy report, CT \
abdomen findings and large ulcer in the stomach, patient was operated for partial Gastrectomy with Billroth II at SGRH. Resected specimen
did not show evidence of adenocarcinoma on histopathology.
Subsequently patient was treated at AIIMS and investigation reports
revealed, ulcerated lesion in afferent loop of gastrojejunostomy on
endoscopy, small bowel stricture on barium meal follow through, and strictures in colon with normal intervening mucosa on colonoscopy.
Based on these nvestigations and colonic biopsy report, patient was considered to be suffering from IBD (Inflammatory Bowel Disease) ‘? 'Crohn’s disease for which he was managed at AIIMS. Patient gradually deteriorated and died after 18 months of operation. Based on the records, the committee is of the opinion that the management of the patient at SGRH (Sir Ganga Ram Hospital) was on the standard accepted guidelines and there is no case of apparent medical negligence in the management of the case.
Dr. Gaurav Pradhan Dr BC Sharma Dr. Vinay Kamal Dr. Anil Agarwal
Professor Radiology Professor GE Dir. Professor, Pathology Prof. & Head GI
MAMC & LNH, Delhi GBPH, Delhi MAMC, Delhi Surgery, GBPH
Dr. Manju Mehra
Chairperson (Medical Board)
Lok Nayak, Hospital
The complainants on their part have not lead any evidence to contradict the above expert opinion of a panel of doctors. Even otherwise from the medical treatment record of Ravi Malik, we are convinced that there was no medical negligence on the part of the OPs.
The discharged summary dated 20/01/2006, the operation notes dated 04/01/2006 show that the patient was suffering from gastic perforation with peritonitis at the time of his admission. A laparoscopic repair of perforation with
peritoneal lavage was conducted on 04/01/2006. The patient was again admitted to the hospital on 20/03/2006. An endoscopy was done & biopsy was taken. A CT scan was also undertaken. The biopsy & CT scan reports were suggestive of adenocarcinoma (malignancy). The endoscopy report also showed ulcerative growth 2 x 2 cms, on the lesser curvature of the stomach and there were large nodes on bare eye vision. Therefore gastrctomy was done on 26/03/2006 for definitive diagnosis & treatment and the excised specimen was sent for histopathology. The report received from histopathology ruled out malignancy. The medical treatment record shows that after the above report was received chemotherapy was not administered to the patient and he was discharged in stable condition on 21/04/2016. In Bailey & Loves short practice of surgery similar procedure is prescribed in these cases. The relevant para extracted as under :
Operations for Gastric Ulcer :
- In contrast with duodenal ulcer surgery, when the principal objective is to reduce duodenal acid exposure, in gastric ulceration the diseased tissue is usually removed as well. This has the advantage that malignancy can then be confidently excluded. Although levels of gastric acid secretion are not abnormally high in the patients with gastric ulceration, acid is still a prerequisite and hence operations have been commonly used to lower acid secretion.
- (Billroth II gastrectomy
This may be used for the high and lesser curvature gastric ulcer where gastroduodenostomy is technically difficult.
The Oxford Textbook of Surgery Edited by Peter J. Morris and Ronald A Malt (Volume I) also prescribed a similar procedure. The relevant para reads as under :
‘’At the time of operation for an acutely perforated duodenal Ulcer
the surgeon must choose between a simple closure of the
perforation or a definitive procedure designed to prevent future
consequences of ulcer disease. Simple closure may be affected
with uninterrupted sutures, an omental or round ligament patch or
closure reinforced with omentum. Care must be taken to and
obstructing the duodenum with sutures. In certain instance a
more radical operation is necessary. Such cases include a giant
perforation that cannot be closed by suture, a large
posterior ulcer, a perforated ulcer on the anterior wall,
or perforation accompanied by profuse bleeding. As was noted
above the most important indication for a definitive operation
is a story of a previous ulcer. Definitive operations can be
carried out successfully at the time of the great majority of
operations for perforation. Appropriate procedures include
gastric resection (with or without truncal vagotomy), pyloroplasty
and bilateral trunal vagotomy, and proximal gastric vagotomy.
Opinions vary concerning the choice of these procedures.
Our preference has been for bilateral truncal vagoromy and
antrectomy, although some surgeons opt for proximal gastric
vagotomy.
Perforated gastric ulcers
The great majority of perforated gastric ulcers are located in
the immediate prepyloric area. They behave in the same way
as perforated duodenal ulcers, and the same considerations
are applicable. However, perforations of ulcers elsewhere in
the stomach introduce the possibility of malignancy, and
immediate definitive resections of the stomach are recommended.
If the patient’s condition is poor, and only a simple closure is
contemplated, biopsy specimens should be taken of the margins of
the ulcer.
Therefore, it can be safely said on the basis of the above medical authorities that the procedure adopted by the OPs was the accepted procedures and which is supposed to be followed in cases such like the patients in this case.
The record shows that after about 09 months of discharge from OP 1 hospital, the patient was admitted to AIIMS on 27/12/2006. He was discharged from AIIMS on 06/01/2007 and the Discharge Summary prepared at the said time records that the patient was investigated for underlying malignancy but the workup was negative. The previous slides also showed no evidence of malignancy. The BMFT (Barium Meal Follow Through) carried on him showed strictures and ulcers in DC (Desending colon) & TC (Transverse colon). A biopsy was conducted and the report dated 03/1/2007 ruled out any evidence of malignancy. The treatment report was suggestive of IBD, crohn’s disease, ITB.
The patient was again admitted to AIIMS on 14/05/2007 and was discharged on 02/06/2007. The Discharge summary inter alia reads as under :
Final Diagnosis : Ch. Malabsorption (uclero – structuring disease)
? Cohn’s disease
Post Billoroth II status
31 years male, history of rec. abd. Pain since Sept, 2005, underwent spont. gastric perforation in January 2006, laparoscopic repair was done in SGRH. Post surgery endoscopic Bx was S/o adenocarcinorna stomach hence partial gastrotomy with Billroth II surgery was done. However post surgery resected specimen was negative for malignancy. He continued to have rec. abd. pain and lost ~ 30 kg weight in subsequent 1 year and got opoid addict. He was admitted and evaluated under GE in AIIME was found to have ulcer constrictive multifocal disease (in afferent loop, descending colon, transverse colon, terminal ileum) Bx was not contributing suspected as IBD? Crohn’s disease & showed on immuno suppresents. However, he responded only partially. (Poor wt gain, effort intolerance, B/L pedal edema). Hence, was admitted for revaluation. At admission he was malnourished, having anemia. B/L pedal edema, low albumin. Dexa scan was S/o serum osteoporosis and
osteopenia. H2 breath test was S/o upper small bowel bacterial overgrowth. He was planned for repeat UGIE/ colonoscopy and biopsy and MR enteroclysis but patient was refuted for same, hence were deferred he is being continued on immunosuppressant and antibiotics.
A perusal of discharge summary and the expert opinion in this case as extracted above rule out any medical negligence on the part of the OPs.In our opinion as well the OPs had resorted to the standard medical practice required in this case.
The treatment was conducted by qualified doctors.We are therefore of considered opinion that the Complainants have failed to prove a case of medical negligence on the part of the OPs.We see no merits in this case, the same is hereby dismissed.Copy of the order be supplied to the parties as per rules.
Announced on this ___________day of __________2018.
