PER DR. S.M. KANTIKAR, MEMBER

1. The Complainant, Shaminder Kaur, wife of Sh. Late Tejinder Singh, (herein after the ‘patient’), Complainant No. 2, Mr. Akashdeep Singh, son of the Complainant, and Complainant Nos. 3 & 4, Ms. Amandeep Kaur & Ms. Arshdeep Kaur respectively, are the daughters of the Complainant, together filed this Complaint, under Section 21(a) (i) of the Consumer Protection Act, 1986, against The Batra Hospital & Medical Research Centre , OP-1(in short Batra Hospital) and two doctors, Dr. U. Kaul, Angiologist, OP-2 and Dr. T. S. Mahant, Cardiac Surgeon, OP-3.

Relevant facts in this  complaint:

1. The patient, Mr. Late Tejinder Singh, aged about 45 years, suffered heart attack on 03.10.2000 and he was admitted to Amar Hospital, Patiala where he was treated by Dr. Sudhir Verma and later was discharged him, on 08.10.2000. Soon thereafter, the patient again suffered chest pain, which was diagnosed as Angina Pain (Anginitis) by Dr. Sudhir Verma. The pain did not subside despite treatment, hence, Dr. Sudhir Verma   referred the patient to  Batra Hospital ( the OP-1). Patient was admitted to OP-1 hospital, on 14.10.2000, under observation of OP-2 i.e. Dr. U. Kaul. The OP-2 performed angiography on 15.10.2000, which revealed two blockages in the arteries,75 to 80% each. Hence, patient was immediately operated for CABG on 16.10.2000, without any prior investigation, and then shifted to ICU on 17.10.2000. The patient complained of trembling and acute debility on 19.10.2000, but the doctors did not pay any attention, hence the patient became unable to walk. The patient developed fever on 20.10.2000, body was trembling, and one unit of blood was transfused. The Complainant also met Dr. Mahant, OP-3, who also examined the patient casually, when patient, had fever of 102° C. The complainant further alleged that on 22.10.2000, when the patient was still in ICU, he fell in the bathroom at 11.30 p.m. and eventually died at 06.50 a.m., on the next day..  The OP certified the cause of death as, “Shock due to Gastro intestinal hemorrhage (GI) and Cardiac failure. On enquiry the OP stated that the GI bleeding was due to stress ulceration and due to prolonged use of anti-coagulants.  Hence, the Complainant alleged that the OP-hospital and doctors ignored the warning signals and did not take due care which caused death of patient. Alleging medical negligence and deficiency in service by the hospital (OP-1) and the doctors (OP-2 & 3), the complainants filed this complaint and prayed for total compensation of ₹41,80,000/-  from the OPs.

Defense:

1. The written version was filed on behalf of OP- 1 to 3 and they have admitted that,  the patient had Myocardial Infarction (MI) , i.e. heart attack on 03.10.2000. He suffered pre-infarction of angina a day prior to MI. Thereafter, the patient was admitted to OP-1 on 14.10.2000 at about 07.15 p.m. The OP performed angiography on the next day which revealed that, the patient was suffering from Triple Vessel Disease (TVD) consisting of severe disease in the Left Anterior Descending (LAD) and Circumflex arteries. Due to involvement of left main artery, the patient was advised for emergency CABG surgery on 16.10.2000. The OP denied that necessary tests were not performed. Thus, for a patient having TVD coupled with tight left main and recent episode of myocardial infarction and post MI unstable angina, the proper treatment was CABG , which was successfully performed by doctors at OP.
2. According to OP-2, the CABG was a major surgery thus; it was quite obvious that the patient will feel weakness. The patient’s hemodynamic was normal and the medicines ionotropes were tapered down, the post operative recovery of the patient was normal, hemoglobin was normal, but the patient had weakness. On 5^th Post Operative Day, the patient was running fever at  100°c, he took oral diet i.e. breakfast, lunch and dinner. Later on, the patient was running mild fever; his blood pressure was monitored on hourly basis and was found, within normal limits, the fever was treated with necessary medicines. OP submitted that after CABG surgery, the patient should be mobilized at the earliest. Hence, the patient was shifted to step down ICU and was allowed to walk for a short distance. OP further submitted that on the night of 21^st Oct , while urinating, the patient had giddiness and fell in the bathroom. He was immediately attended to by the nurse waiting outside the door. On examination, it was found that, the patient was suffering from hypertension; there was no visible bleeding from ear, nose and mouth, etc. He was resuscitated; Ryle’s tube was inserted in the stomach and huge quantity blood stained fluid was aspirated out. This was suggestive of upper GI bleeding, because of stress ulceration in the stomach. OP made all possible efforts to treat the GI bleeding, but unfortunately, the patient did not survive.
3. I have heard the arguments advanced by the learned Counsel for the parties. The Counsel for complainant reiterated the sequence of events and the negligent attitude of OPs.  The Complainant No.1 was never informed by the OPs at that time that, her husband had bled to his death due to a fall in the bathroom. Counsel submitted that, it remains a big mystery, and it was negligence on part of the OP to have allowed the ICU patient to go to the bathroom all by himself without the assistance of a nurse or an attendant. The patient was running high temperature, abnormal blood pressure and also complaining of uneasiness and giddiness. It was perhaps only as an afterthought and with a view to hide   the real cause of death of the said Sh. Tejinder Singh, the doctors and nurses in the ICU and the OPs mentioned that, the probable cause of death was due to excessive bleeding due to a fall in the bathroom.  The Complainant No. 1 took medical opinion from various doctors about the causes of GI bleeding, and learnt that it may be due to high BP, internal bleeding, hemorrhage, post operative infection inside the body due to negligence and non compliance of health safety and sanitation guidelines, etc.
4. The counsel for OP argued that, OP No.-2 is an MBBS, MS and Head of Cardiac Surgery Department with OP-1. He has worked in Australia, USA and was also a Professor at GSPGI MS, Lucknow (UP). The OP-2 has carried out over 15,000 CABG (Coronary Artery Bypass Grafts) and dealt with virtually, every conceivable emergency of coronary artery disease. The CABG was performed because of severe left main artery diseases and the patient had  recent history of myocardial infarction and post MI angina. The surgery   was successful. On 5^th POD, the patient was febrile, by afternoon. Blood investigation revealed Total Leucocyte Count (TLC) as 6.000/cmm and differential count ( DLC) within normal limit. Blood was sent for Culture and Sensitivity.  At around, 11.30 p.m. patient had giddiness and fell in the bathroom, detected to have BP 80/40. Dopamine drip was started but BP did not improve. Patient was shifted to ICU for intensive monitoring. Adrenaline was started but there was no change in BP. Central line put and the BP stable for 2 hours (<110 systolic) BP dropped. Intubated put on 1 PPV NG tube revealed massive upper GI bleed. FFP, blood transfusion. Had arrest resuscitated. Patient did not sustain for long, again suffered cardiac arrest and declared dead, due to shock following GI hemorrhage and cardiac failure at 6.50 a.m. on 22.10.2000. The counsel for OP brought my attention to the opinion of Medical Board that OP-1  Batra Hospital and OP-2, Dr. U. Kaul and OP-3, Dr. T. S. Mahant followed the established medical procedure in pre-operative diagnosis, timely CABG surgery and  post-operative care.

Findings:

1. I have perused the medical records and the opinion of medical board. The committee of Medical Board made it’s observations on the basis of charts, investigation sheets, medication orders, operation and progress notes. Medical Board’s observations are as under:

1. With the diagnosis of left main disease, operation is indicated as an urgent/semi-urgent measure depending on the degree of obstruction. Therefore, operation (coronary artery bypass grafting) was warranted.

1. The medical records revealed that the post-operative recovery was uneventful in terms of cardiac function. There was no evidence of low cardiac output syndrome.

1. However, there was fever, leucocytosis and some wound discharge. The severity of infection could not be assessed from the hospital records provided to the committee.

1. The attributed cause of death from the medical records appears to be bleeding from the stomach secondary to stress ulceration. Stress ulcer of the stomach following cardiac surgery is a well known event. Whether patient had any pre-existing undiagnosed gastric/duodenal ulceration with subsequent bleeding precipitated by post-operative aspirin administration is difficult to ascertain. Normally, with the diagnosis of left main coronary artery disease, we do not do diagnostic gastro- duodenal endoscopy unless there are strong indications.

1. Medical Boarid’s Opinion  as hereunder :-

          The members of the board, duly constituted for the said purpose after having examined the documents provided unto them and in the light of observation made as above, are of the considered opinion as below:

1. Batra Hospital and the attending Cardiologist Dr. U. Kaul and cardiac surgeon Dr. T. S. Mahant followed the established medical procedure in pre-operative diagnosis, timely surgery and post-operative care so far as the treatment is concerned.
2. From the records provided there is no obvious medical negligence on the part of the treating physicians of the Batra Hospital.
3. From the medical reports, it appears that bypass of 3 branch coronary arteries was warranted.
4. The Medical Board is unable to give any opinion regarding the presence or absence of attendant in the ICU and while he went to the bathroom; as it is out of the scope of the medical board.
5.  

1. It is important to decide, two main questions in this case are, whether there was any negligence by the OP 2 and 3 doctors in diagnosis and during the treatment of the patient? Or Whether the OP-1 hospital was deficient in its services during treatment? After the thoughtful consideration, I have placed reliance upon the medical literature on the subject of CABG and the Stress Ulcers, and the Medical Board’s opinion, it is clear that, the patient was suffering from left main artery disease, CABG operation was warranted, accordingly OP doctors performed the CABG, which was not an act of negligence on the part of OP-1and 2. The Medical Board expressed that due to stress ulceration, the GI bleeding was the cause of death. The medical literature also supports this view, that the stress ulcer of the stomach following cardiac surgery is well known even. I do not find any fault with OP who did not perform Endoscopy or Colonoscopy in this patient after CABG, because there was no previous history of the patient about GI pathology.
2. Medical Negligence has been discussed in several judgments of Hon’ble Supreme Court and this commission. The Hon’ble Supreme Court held in C. P. Sreekumar (Dr.) vs. S. Ramanujam, (2009) 7 SCC 130,  case as follows:-
   • the onus to prove medical negligence lies largely on the claimant and that this onus can be discharged by leading cogent evidence. A mere averment in a complaint which is denied by the other side can, by no stretch of imagination be said to be proved. It is the obligation of Complainant “to provide the facta probanda as well as the facta probantia”
3. In the case Supriya Gupta vs. Trustees of Beach Candy Hospital & Research Centre, IV (2005) CPJ 261 (NC), it was held by this commission that “hospital cannot be blamed by theories based on probabilities.” 
4. In the case of Kusum Sharma vs Batra Hospital Hon’ble Apex Court observed that, “the normal human tendency is to pick fault whenever there is a death in the family for which the doctor cannot be made a scapegoat. It is a matter of common knowledge that after some unfortunate event, there is a marked tendency to look for a human factor to blame for an untoward event, a tendency which is closely linked with the desire to punish. Things have gone wrong and, therefore, somebody must be found to answer for it. Finding such CPA complaints against doctors on the rise and in many cases these being frivolous, the Bench said, "Courts have to be extremely careful to ensure that unnecessarily, professionals are not harassed and (or else) they will not be able to carry out their professional duties without fear."
5. Regarding the question, whether there was deficiency in service by OP-1 hospital during treatment/management of patient? It is apparent from the medical records that, the deficiency in service on the part of hospital is limited one to the extent that, there was no one staff or attendant in ICU while patient was going for urination on the late night of 21.10.2000.  The patient was unattended. It is clear from the Medical Board’s Opinion (supra), the last paragraph (No.4) is not conclusive one.  Thus, the ICU staff was not vigilant, and negligent in their duty.
6. Therefore, on the basis of entire discussion, in my opinion there was no fault of doctors OP-2 and 3, the decision of conducting CABG was correct, and they followed established medical procedures. The CABG was successful, but during post operative period the patient suffered GI bleeding due to Stress Ulceration, leading to death. Thus, the death was not due to negligence of doctors. Whereas, the hospital OP-1 is held liable for the deficiency in service due to laxity of ICU staff. Accordingly, the Complaint filed against OP-2 and 3 is dismissed, and the complaint against OP-1, the hospital is partly allowed. The OP-1 is directed to pay total sum of ₹ 2,00,000/- to the complainant, within 90 days, otherwise it will carry interest @ 9% per annum till it’s realization.

 Hence, the complaint is dismissed.