OP.82/99

JUDGMENT DATED:08..03..2012

PRESENT

JUSTICE SRI.K.R.UDAYABHANU  : PRESIDENT

1. Narayanan Kutty,                                               : COMPLAINANTS

    S/o Sankaran,

    Perumanath House,

    Marangattattikara,

    Thruvaniyoor Village, Thiruvaniyoor.P.O.,

    Kunnath Nadu Taluk.

2. Alley Narayanan Kutty,

    W/o Narayanan Kutty,

                -do-do-

3. Sajini aged 14,

    D/o Narayanan Kutty,

           -do-do- rep.by father

    And Natural guardian

    Narayanan Kutty.

4. Santhosh, aged 24,

    S/o Narayanan Kutty

            -do-do-

(By Adv.P.Sunil Nair)

1. The Ernakulam Medical Centre Hospital,   : OPPOSITE PARTIES

     N.H.Bye Pass, Palarivattom,

     Cochin -28 rep.by its Manager.

2. Dr.Dinesh Psychiatrist,

    Ernakulam Medical Centre,

    Cochin- 28.

(By Adv.S.Krishnamoorthy, counsel for Opposite parties 1 and 2)

3. Dr.Antony thachil,

    General Physician,

    Ernakulam Medical Centre.

(By Adv.A.K.Basheer)

JUDGMENT

JUSTICE SRI.K.R.UDAYABHANU  : PRESIDENT

          The complainants are the parents, brother and sister of the deceased Mr.Sajeevan who died on 26.11.98 in consequence to attempt to commit suicide by jumping from the top floor of the 1^st opposite party hospital.  The deceased at the time was admitted in the medical ICU of the above hospital.  It is the allegation that the deceased was having psychic problems and was under treatment for the same and that the opposite parties did not take adequate care to see that the patient is kept under close guard.  The deceased was a 2nd year Automobile Engineering student studying at the Polytechnic, Kalamassery.  On complaint of fever he was taken to Dr.Varghese, Assistant Surgeon, Government Hospital, Vadavukode on 19.11.98.  As there was no improvement on 20.11.98 he was taken to Karuna Medical Centre, Thripunithura and there from he was referred to a  Psychiatrist and hence the patient was taken to the 1^st opposite party hospital wherein he was admitted on 20.11.98 at 11PM.  On the next day he was examined by the 2^nd opposite party Psychiatrist of the opposite party hospital. Dr.Dinesh Kammath. Neurologist also examined the patient. On the same day CT scan of the brain was taken and the treatment was continued for psychiatric disorder.  He was admitted in room No.307.  On 23.11.98 the patient became violent on account of psychiatric problems.

          2. According to the complainant he was then shifted to ICU as directed by the opposite parties 2 and 3 the Psychiatrist and Physician of 1^st  opposite party hospital.  The bystanders were not permitted in the ICU.  In the ICU the patient is supposed to be under the constant watch and vigil of a unit managed by a doctor and nursing assistant.  The days 24^th  and 25^th were uneventful.  At about 4.50am in the morning of 26.11.98 the nursing assistants came to room No.307 where the bystanders were staying and enquired  about the patient. By 5.30am the bystanders were informed that the patient  jumped  from the top floor of the hospital and that he is in serious condition. He succumbed to the injuries at 6.30AM. The complainants have claimed a sum of Rs.19,50,000/- as compensation.

          3. 1^st opposite party hospital represented by its Managing Director has filed version that the patient was admitted on 20.11.98 at 11PM with a history of fever since 3 days and he was under treatment at a local hospital for fever and was reportedly disoriented and talking irrelevantly since morning. The duty doctor was also informed that the patient has a history of black out one month back.  Consultation with the psychiatrist and medical consultation was also suggested by the duty doctor.  The Psychiatrist and Physician had also examined the patient on 21.11.98 in order to find out whether there was  any organic brain illness since the  patient was having fever along with abnormal behaviour. The patient was having fever of
100⁰ F.  There was no neck stiffness and kernigs signs were negative.  Since a history of fall and a consequent hit on the head resulting in a head injury was given  the 3^rd opposite party Physician had advised CT scan of the brain as well as a CSF study.  After seeing the scan report the same were directed to be done inorder to rule out meningoencephalonlitis since the patient  had presented with fever and abnormal behaviour. Blood and urine routine examinations in addition to widal,  mantoux, smear for malarial parasite etc. were done. As no specific diagnosis could be arrived at Neuro Physician Dr.Dinesh Kammath  also examined the patient and was under his care. There was no neurological deficits was the observation of the Neuro Physician also.  Antibiotics (Amclox), taxim, tab zevit, tab dolo were prescribed along with the other medicines prescribed by the Neuro Physician and Psychiatrist. At about 7.30pm on 23.11.98 the patient was showing some involuntary movements.  Immediately the same was reported to the 3^rd opposite party Psychiatrist. On examination it was found that there were some involuntary movements of the lips.  His  cardio vascular system was also normal.  Diazepam injection and injection epsolin was administered and the Neurologist Dr.Disnesh Kammath was informed.  The patient was removed to the medical ICU so that he could be observed and monitored continuously in the light of the involuntary lip movements.  On 24.11.98 Neuro Physician advised to avoid sedatives  which were likely to create confusion in  Neuro psychological evaluation and  further suggested to give injection Sernace only if absolutely necessary.  The electroencephalogram was taken as advised  by the Neuro Physician.  The findings were normal in the EEG.  The Neuro Physician was also advised.  Other tests like ESR, ANA etc were done.  On 25.11.08 also the doctors were examined  the patient and found that his vital signs were within normal limits.  Low grade temperature persisted even though he was under antibiotics.  Neuro Physician advised MRI scan to rule out Accute Disseminated
Encephalomyelitis (ADEM).  The patient was conscious, alert and was talking relevantly at times and irrelevantly at other times.  He refused to talk occasionally.  He was resting in bed and used to go to bathrooms for passing urine.  Primary psychiatric problem was also considered a possibility.  Although MRI scan was advised on 25.11.98 the father of the patient informed that the scanning can be done on the next day as he was not able to raise sufficient money for the scan on 25^th.  At about 4.30pm on 26.11.98 the patient got out of his bed and attempted to go out of the ICU. The Nurses tried to prevent him.  The patient had pushed aside the duty nurses who had caught  hold of him and ran out from the ICU.  Though the duty nurses ran after him but he escaped from the eye sight.  Duty Nurses and male nurses tried to trace him  and alerted  the security staff.  At last it was found that he had jumped from the top of the hospital and lying in the ground.  He was immediately rushed to medical ICU  and was attended by the duty doctors.  At about 5pm the 2^nd opposite party the Neuro Physician and the Anesthetist  also came and administered medicines and was also connected to the ventilator. All the attempts of resuscitation failed and the patient died  at 6.30am.  It is stated that the first time he showed any violence was at 4.30 am on 26.11.98 when he pushed aside the nurses forcefully and ran out of the ICU. Till that time   there was nothing in his behaviour to suspect any violent behaviour.  No additional security staff is provided in the ICU. It is the duty nurses and male nurses that the mange the condition of the patient in the ICU. The behaviour  of the patient on the 26^th was not predicted or anticipated.  1^st opposite party had denied any negligence on the part of the staff of the hospital in taking care of the patient.

          4. The 2^nd opposite party, the Consultant Psychiatrist attached to the 1^st opposite party hospital has also filed version containing in the contentions as in the version of the 1^st opposite party.  It is mentioned therein on the 23^rd the patient became restless and showed some involuntary movements (not typical of seizures). It is not correct that the patient became violent on account of  psychiatrist disorders. The Physician also saw him and advised to administer injection diazepam and injection epsolin and shift the patient to medical ICU.  On the next day the Neuro Physician advised to avoid sedatives as far as possible and give injection Seranace if at all the patient became agitated.  EEG was taken in the after noon was normal.  It is also advised to have MRI scan of the head to rule out ADEM.  It is mentioned that various tests were done to rule out the possibility of any medical pathology and neurological problems.  He was admitted in the ICU for the neurological problem of involuntary lip movements noticed on the 23^rd  and had indicated  that further investigations to rule out any neurological problems may be necessary. The past history of a black out and a head injury had further complicated the diagnostic procedure.  He has also denied any negligence or lack of care on his part.

          5. The 3^rd opposite party/Physician has also filed version similar to that of opposite parties 1 and 2.  It is specifically mentioned that patients with psychiatric disorders are not admitted in the ICU. It was on account of suspected neuro problems that he was admitted in the ICU and treated for the same. The persistent temperature and the abnormal pattern of behaviour which were not exactly akin to psychiatric disorders  had given conflicting  impression.  It is further pointed out that psychiatric patients are not even admitted in the general ward where patient for other ailments are being treated.  It is mentioned that the best possible care and attention was given to patient. All efforts were made to diagnose his condition.  It is also pointed out that the police had referred the case   after due investigation although the complainants have moved  the police authorities have taking action against the opposite parties.

          6. The evidence adduced consisted of the testimony of PWs 1 to 3, DWs 1 to 3; Exts.A1 to A8 and B1.

          7. Ext.B1 is the photocopy of the case sheet subsequently as the original could not be produced as the same was reportedly seized by the police.

          8. PW1 the 1^st complainant/father of the deceased has filed proof affidavit in proof of the averments contained in the complaint and was also cross examined.  He has stated in the cross examination that at first the deceased was taken to the local hospital on 16.11.98  as the  fever did not subside he was taken to  Karuna hospital at Thripunithura and that the doctor therein directed the patient to be examined by a Psychiatrist and hence he was taken to the opposite party hospital.  He is not aware as whether any reference letter was given as the patient was taken to the hospital by his another son and a friend.  It was on 23^rd at thatthis son started refusing to obey instructions.  He was not allowing to administering injections.  It was then that he was shifted to ICU.  He was not  attending patient in the hospital and hence could not answer questions with reference to treatment as such.  He has denied that his son had sustained a head injury earlier.

          9. PW2 the neighbour and friend of the deceased who was the bystander at the hospital has testified that the deceased was speaking irrelevantly on account of high fever and that he was taken to the government hospital and thereafter to the private hospital at Thripunithura and that the doctor of the private hospital suggested to consult a Psychiatrist as the deceased was talking irrelevantly due to  high fever and that on the same day he was admitted at the opposite party hospital. According to him the deceased became violent on 23^rd and there after he was admitted at ICU.  He has also denied that the deceased had sustained head injury. 

          PW3 is the present Principal of the Polytechnic.  He has stated that only students with good academic records would got admission at Govt. Polytechnic.  He has not seen the deceased and was not working in the Polytechnic at the time of the incident.

          10. DW1 the Managing Director of the Hospital who himself is a doctor has testified on behalf of the hospital and as per the averments in the version.  It was brought out in the cross examination that the patient was brought to the 1^st opposite party hospital as psychiatric patient as referred by Dr.Ajay from Thripunithura.  It was fever and abnormal behaviour that the complainant was having.  He has also stated that the deceased was the patient of the 2^nd opposite party/Psychiatrist.  He has also asserted that a patient having psychiatric disorder will not be admitted in the ICU.

          11. DW2, Psychiatric Consultant  of 1^st opposite party hospital has testified that on examination he felt that the patient was in a delirious state due to organic illness of the brain.  He was stated that the patient was having history of black out one month back.  He has stated that no psychiatric treatment was provided to the patient.  He had administered medicines to control behaviour problems in the delirious state.  He has also stated that haloperidol injection and phenergan injection were administered.  Sernace was also administered. Sertalin was administered as the patient had slight anxiety. As directed by the Neuro Physician  injection Sernace and Epsolin was stopped.  He has admitted that Sertalin as per the Recommendations of the Food and Drug Administration if the same is administered to persons aged 18 to 25 as antidepressant there will be suicidal tendency and that they should be closely monitored.  But the same is not the case in the matter of the deceased.  He has stated that only a minimum dose of Sertalin was administered to the deceased and that on account of the same there is no chance of having the suicidal tendency.  He has also stated that diazepam was also given to the deceased in a minimum dose. If the patient is in a delirious state  he may show violence.  He has stated there will be no side effect if the above medicines is administered in the proper dose.

          12. DW3 is the Chief Physician of the opposite party hospital.  He has also stated as to the history of black out of the patient  about one month back and also  as to the history of a fall and consequent hit on the head resulting in the head injury. Hence CT scan of the brain was advised along with CSF study.  All tests were done to rule out meningoencephalitis since the patient had presented  with fever and abnormal behaviour. As the Neuro Physician has to make a proper evaluation the patient was referred to the Neuro Physician attached to the hospital on 21.11.98.  DW3 has also examined the patient thereafter and had prescribed antibiotics.  The deceased was administered with medicines prescribed by  the Neuro Physician and Psychiatrist.  There was no neck stiffness and kernigs    sign.  At about 9.30pm on 23.11.98, the patient was showing some involuntary movements.  Then he examined the patient and found some involuntary  movements of the lips. Hence he advised diazepam injection and injection epsolin and he directed nurse to inform the Neuro Physician and to remove the patient to the MICU so that he could be  observed and monitored continuously in the light of involuntary lip movements.  On 24.11.98 he had again visited the patient. The Neuro Physician had also examined him and advised to avoid sedatives as it is likely to create confusion in neuropsychological evaluation and directed to give injection Sernace only if absolutely necessary.    Neuro Physician advised EEG and other blood tests although  there was no neck                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           rigidity. Low grade temperature was persisting eventhough he was still under antibiotics.  Hence MRI scan was suggested to rule out ADEM.  The same was not done on 25.11.98 as the father of the deceased could not raise money on that day. A psychiatric problem was also considered as a possibility.  The past history of black out and head injury had complicated the diagnostic procedure.  The erratic behaviour shown by the patient was totally unexpected till that time .  There was nothing in his behaviour to suspect any violence on the part of the patient.  DW3 is the doctor having 27 years of experience.

           He has explained in the cross examination that the patient was having involuntary movements like fits on the lips.  The treatment was provided in consultation with the Neuro Physician.  He has stated that with one dose of diazepam there will be no tendency to commit suicide. Such tendency is possible due to long usage.  More of a possibility of organic brain disease was considered as he had fever and fits. If there is fever there will be infection.  In such cases abnormal behaviour is shown and if the patient is violent  in such cases the Psychiatrist used to be consulted. Only with an MRI scan a proper diagnosis as to whether the infection has affected the brain can be made.  On the clinical judgment there was such a possibility.  He has also stated that in the case of the particular patient as there was fever and fits there was a possibility of developing  into severe fits and hence there should be facility for emergency treatment and even the use of ventilator and that was why he was admitted in the ICU. 

          We find that in Ext.B1 case sheet the history of black out one month back is noted.  In the consultation record(Ext.B1) on 25.11.98 it is mentioned that when seated he tended to fall to the bed.  It is also noted that when he was made to stand and asked to walk he could walk without support.  It is also mentioned that he used to talk to the nursing staff at times and wanted to go to the room. The possibility  of  primary psychiatric problem is considered as the 1^st possibility and suggested MRI scan to rule out  the rare possibility of   ADEM  is advised. At 6.30pm on the same day also  it is mentioned that at times he answers to questions properly and at times he refuses to talk. The above period was just hours prior to the date of the incident of fall from the top of the hospital.  Evidently at the time he was rather weak.

          13. On 24.11.98 it is noted that on yesterday night he had shown abnormal behaviour with shouting and violent nature and injection diazepam was given at that time and he was found sedated since then.  Evidently since 23.11.98 there was no administration of diazepam.  Admittedly the patient was treated by the specialist doctors in Psychiatry, Medicine and Neurology.  It was persisting fever that lead to the suspicion of the possibility of organic brain illness.  Although it was on account of the head injury and black out noted in the history that caused doubt as to the infection of the brain. It is the case of the opposite parties that some sort of abnormal behaviour will be shown by the patient afflicted with ADEM It has also noted that although in the version filed by the opposite parties  the case of head injury and black out that the patient was having previously  was specifically mentioned  the same was not denied in the proof affidavit filed by DW1 or in the examination in chief of PW2.  It is only when specifically questioned in the cross examination that they have denied that the complainant had a head injury.  In the circumstances it appears that PWs 1 and 2 are not speaking the truth. Evidently it is only for providing emergency care and constant monitoring in view of the involuntary lip movements and fever that the patient was shifted to the ICU.  All possible tests ie CT scan, CFS study, EEG and blood test were done.  MRI scan although advised   could not be done as the father of the deceased could not raise money for the same.  It has also to be noted that the Neurologist, Physician and the Psychiatrist in consultation treated the patient. What was the illness as such could not be diagnosed finally.  No medical literature has been produced to substantiate that the medicines administered in such doses would result in suicidal   tendency.  Evidently the specialist doctors would not have directed shifting to the ICU if the patient was violent as in the ICU it is critically ill patients who are admitted. Further just an error in judgment or such a mistake in diagnosis cannot be considered as actionable negligence on the part of the opposite parties.  In the circumstances we find that the complainants have failed to establish that it was on account of the carelessness and negligence on the part of opposite parties that the patient happened to kill himself. 

          In the result the complaint is dismissed.

          JUSTICE SRI K.R.UDAYABHANU                   : PRESIDENT

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