Chandigarh

DF-I

CC/106/2014

Harvinder Singh - Complainant(s)

Versus

The Government Multi Speciality Hospital - Opp.Party(s)

Hemlata Issar

13 Jul 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

========

 

 

Consumer Complaint No.	:	CC/106/2014
Date of Institution	:	18/02/2014
Date of Decision	:	13/07/2015

 

 

Harvinder Singh son of late Sh. Harbhajan Singh resident of village Parch, P.O. Mullanpur Garibdas, Tehsil Kharar, Distt Mohali, Punjab.

…..Complainant

V E R S U S

1.      The Government Multi-Speciality Hospital, Sector 16, Chandigarh through its Medical Superintendent.

2.      Dr. Pallavi Paschricha w/o Dr. Pradeep Utrija r/o H.No.845, First Floor, Phase-VII, Mohali.

3.      Dr. Sudha, M.O. Gynae Department.

4.      Dr. Nirlep Kaur, Sr. Medical Officer, Gynae Department

          All through Medical Superintendent, GMSH Sector 16, Chandigarh

5.      National Insurance Company, SCO No.4-5, Sector 9-D, Chandigarh through its authorised signatory (insurer of OP No.2)

……Opposite Parties

QUORUM:	P.L.AHUJA	PRESIDENT
	MRS.SURJEET KAUR	MEMBER
	SURESH KUMAR SARDANA	MEMBER

               

                               

For complainant	:	Ms. Hemlata Issar, Advocate
For OP-1	:	Sh. Jatinder Singh, Govt. Pleader
For OPs 2 to 4	:	Sh. Munish Kapila, Advocate
For OP-5	:	Sh. Navin Kapur, Advocate

PER P.L.AHUJA, PRESIDENT

1.         Sh. Harvinder Singh, complainant has filed this consumer complaint under Section 12 of the Consumer Protection Act, 1986, against The Government Multi-Speciality Hospital and others, Opposite Parties (hereinafter called the OPs), alleging that his wife, Mrs. Harjinder Kaur, was pregnant and got admitted with OP-1 on 8.8.2013 for delivery in the 39^th week of pregnancy. Copy of the admit card is at Annexure C-1.  At the time of admission, she was examined by the Medical Officer on duty in CLR (Common Labour Room) and on examination everything was normal and fatal (fetal?) movement was also felt. An ultrasound (Annexure C-2) was also conducted in which everything was declared normal. 

                According to the complainant, after admission, his wife was shifted from ANW (Anti natal ward) and CLR (common labour room) various times and ultimately from 11.8.2013 to 12.8.2013, she remained in the CLR but there was no senior doctor or sufficient staff to look after her.  On 12.8.2013, his wife was crying with pain, but, after inducing labour pain, she was not monitored properly by the doctor and staff on duty, due to which her uterus ruptured causing heavy blood loss resulting in her death and the unborn baby.  The complainant has alleged that when his wife was in such a critical condition, neither there was any senior doctor/gynae available nor the mandatory medical equipments like oxygen cylinder and electronic fatal (fetal?) monitoring devices were available in the CLR. The complainant has contended that from the date of admission till 12.8.2013, his wife remained under the supervision of Hospital authorities and she was normal without having any history of medical problem or operation/caesarean delivery etc. The post mortem (Annexure C-3) conducted by OP-1 also declared the cause of death as shock and hemorrhage due to injury to uterus.  It has further been contended that the enquiry (Annexure C-4) conducted by the HOD Gynae, GMCH Sector 32, Chandigarh and Dr. Soma, DFWO Sector 22, Chandigarh also pointed out lacunae in care of patients in the CLR of OP-1 and declared the cause of death of deceased due to rupture uterus. The complainant has further contended that the death of his wife and child had occurred due to negligence and careless attitude of the doctors and staff on duty.  The wife of the complainant was admitted in General Hospital, Sector 16, Chandigarh (OP-1), OPs 2 to 4 were doctors on duty and OP-5 is the insurer of OP-2.  Alleging that the aforesaid acts amount to medical negligence, deficiency in service and unfair trade practice on the part of the OPs, the complainant has filed the instant complaint. 

2.         In its written statement, OP-1 has taken a number of preliminary objections including that the present complaint is not maintainable as neither the complainant fall within the meaning of expression ‘consumer’ nor the treatment provided to patient fall within the meaning of expression ‘service’ as defined in the Consumer Protection Act.  It has been averred that complainant’s wife, Mrs. Harjinder Kaur was admitted to General Hospital Sector 16, Chandigarh on 8.8.2013 and was being regularly monitored there.  On 12.8.2013 at 6:00 p.m. Dr. Sudha Rani in view of non-descent of the fetal head instructed that the patient be prepared for emergency caesarean section. After preparation of the patient, she was shifted on the trolley and her vitals at that point of time were normal.  She was wheeled out of clean Labour Room on the ground floor towards the Operation Theatre located on the first floor.  The patient collapsed in the corridor and was rushed back to clean Labour Room (CLR) where she was immediately attended to and resuscitated. However, all efforts to resuscitate the patient failed and she was declared dead at 7.55 p.m. After death of the patient, her post mortem was conducted and an independent inquiry committee was formed which in its report found no fault with the line of treatment rendered to the patient at GMSH, Sector 16, Chandigarh. The committee in its report dated 16.7.2014 unanimously opined that the case of the complainant’s wife was of fatal complication rather than negligence and held that the doctors on duty managed the patient as per protocol and could not be held responsible for known complications of pregnancy and its management. It has been contended that oxygen was available 24 hours through pipeline in clean labour room. It has been contended that the team of doctors did their best to revive the patient, but because of catastrophic and fatal nature of Amniotic fluid embolism, prime cause of sudden collapse (with high maternal and fetal mortalities) and also associated uterine rupture, revival was not feasible. It has been pleaded that the patient expired from a known complication, although rare but reported in literature having high fetal morbidity and mortality reported worldwide. The complainant’s wife was provided with optimum treatment and despite best of efforts, she could not be revived. It has further been contended that there was no negligence in the treatment of complainant’s wife. Pleading that there is no deficiency in service or unfair trade practice on its part, OP-1 has prayed for dismissal of the complaint. 
3.         In their separate written statements, OPs 2 to 4 have also taken almost similar pleas as have been taken by OP-1 in its written statement and also prayed for dismissal of complaint.
4.         In its separate written reply OP-5 has averred that best possible treatment was administered by OPs 1 to 4, especially by OP-2. Every effort was made by the OPs to save the wife of the complainant and un-born child; proper monitoring was done by OP-2 on the basis of facilities available and the treatment was administered with due diligence. It has been pleaded that OP-5 had been impleaded as party being insurer of OP-2 and that it cannot be held liable for any act or negligence on the part of the insured. Pleading that there is no deficiency in service or unfair trade practice on its part, OP-5 has prayed for dismissal of the complaint.
5.         In his rejoinder, the complainant has controverted the stand of the OPs and reiterated his own. It has been pleaded that after inducing labour pains surgically, the patient was not monitored properly and immediate medical care was not provided to her due to which her condition became critical and she and her unborn child died. It has been contended that there was fault in line of treatment by doctor on duty, therefore, OPs 2 to 4 are liable for negligence on their part.
6.         The parties led evidence in support of their contentions.
7.         We have scanned the entire evidence, written arguments submitted by all the parties and heard the arguments addressed by the learned counsel for the complainant, learned Government Pleader for OP-1 as well as learned Counsel for OPs 2 to 4.
8.         It is admitted by OPs 1 to 4 that Mrs. Harjinder Kaur w/o Sh. Harvinder Singh (complainant) was admitted in Govt. Multi-Speciality Hospital, Sector 16, Chandigarh (OP-1) on 8.8.2013 vide admit card (Annexure C-1). On that date, her vitals and fetal heart rate were normal and labour had not started.  After her admission, Mrs. Harjinder Kaur was examined and monitored round the clock by a team of doctors including Gynaecologists and trained nurses.  On 10.8.2013, she was shifted to ante natal ward because she had not gone into labour.  On 11.8.2013, she was shifted back to clean labour room and given prostaglandins.  On 12.8.2013, Dr. Swapanjeet Kaur (MO) surgically induced labour by artificial rupture of membrane (ARM) and clear liquor was obtained and labour was augmented by starting Pitocin.  At 2:00 p.m. on 12.8.2013, the shift of Gynaecology Department of Government Multi Specialty Hospital, Sector 16, Chandigarh (OP-1) changed and Dr. Sudha Rani and Dr. Pallavi Pasricha alongwith House Surgeon, Dr. Shabdeep took charge.  Dr. Nirlep Kaur, Head of the Department of Gynaecology & Obstetrics was the doctor on call. At 2.30 p.m., Mrs. Harjinder Kaur was examined by Dr. Sudha Rani and was found to be in active phase of labour and Dr. Sudha Rani took decision to continue augmentation with Pitocin. At 6:00 p.m., she was again examined by Dr. Sudha with Dr. Pallavi, the cervix was fully dilated and decision for emergency caesarean section was taken in view of non descent of fetal head.  Thereafter Dr. Sudha left for operation theatre for exploration of hematoma of another patient, Ms. Kulwinder Kaur and Dr. Nirlep Kaur was also there.  Following the instructions from Dr. Sudha, the patient was prepared for C-Section. At 6:15 p.m., Dr. Pallavi examined the patient, her vitals were normal and fetal heart rate had just started dipping intermittently but was picking upto 110 beats per minute (lower limit of normal range).  At 6:30 p.m., the patient was ordered to be shifted to operation theatre and Dr. Pallavi was called by the staff nurse to attend a new patient in the Gynaecology emergency.  As the trolley was wheeled out of the labour room towards the operation theatre, the patient suddenly collapsed in the corridor. Dr. Pallavi was immediately informed, who at that time was in the Gynaecology Emergency examining a patient, and she immediately rushed towards the CLR. Simultaneously senior doctors were informed in the operation theatre and Dr. Nirlep Kaur rushed to the CLR.  Dr. Pallavi examined the patient and found that she was pulseless and BP was not recordable. She immediately started with CPR (according to ACLS guidelines), oxygen inhalation, fluid replacement emergency/cardiotonic drugs and was soon joined by Dr. Nirlep Kaur. Urgent call was also sent to physician, surgeon, anesthetist. The patient was intubated and CPR continued. However, despite efforts, Mrs. Harjinder Kaur could not be revived and was declared dead at 7.55 p.m. 
9.         The first objection raised by the learned counsel for OPs 2 to 4, assisted by the learned Govt. Pleader for
   OP-1, is that the complainant does not fall within the meaning of expression ‘consumer’ as defined in Section 2(1)(d) of the Consumer Protection Act because no consideration for the said delivery case was paid and the treatment provided to the patient does not fall within the meaning of expression ‘service’ as defined in Section 2(1)(o) of the Act. The learned counsel/Government Pleader for OPs 1 to 4 have drawn our attention to Major Singh Vs. State of Punjab & Ors., Revision Petition No.4734 of 2012 decided on 5.11.2014 by the Hon’ble National Commission and have contended that in a hospital where the doctors and hospitals do provide free service to some of the patients belonging to the poor class but the bulk service is rendered to the patients on payment basis, the expenses incurred for providing free service are met out of the income from the service rendered to the paying patients. The learned counsel for OPs 2 to 4, assisted by the learned Government Pleader for OP-1, has vehemently argued that in the light of the observations in Major Singh Vs. State of Punjab & Ors. (supra), it becomes clear that where services are rendered free of charge, patient does not fall within the purview of ‘consumer’ as defined in the Consumer Protection Act. 
10.         We have carefully considered the above arguments.  It is significant to note that the ruling Major Singh Vs. State of Punjab & Ors. (supra), is based on an Apex Court  judgment Indian Medical Association Vs. V.P. Shantha & Ors.-1996 AIR (SC) 550.  In that case, the Hon’ble Supreme Court examined the exclusionary part of definition of ‘service’ contained in Section 2(1)(o) of the Consumer Protection Act and observed as under :-

“44.  The other part of exclusionary clause relates to services rendered "free of charge". The Medical Practitioners, Government hospitals/nursing homes and private hospitals/nursing homes (hereinafter called "Doctors and hospitals") broadly fall in three categories:—

(i)     where services are rendered free of charge to everybody availing the said services;

(ii)    where charges are required to be paid by everybody availing the services; and

(iii)   where charges are required to be paid by persons availing services but certain categories of persons who cannot afford to pay are rendered service free of charges.

There is no difficulty in respect of first two categories. Doctor and hospitals who render service without any charge whatsoever to every person availing the service would not fall within the ambit of "service" under Section 2(1)(o) of the Act. The payment of a token amount for registration purposes only would not alter the position in respect of such Doctors and hospitals. So far as the second category is concerned, since the service is rendered on payment basis to all the persons they would clearly fall within the ambit of Section 2(1)(o) of the Act. The third category of Doctors and hospitals do provide free service to some of the patients belonging to the poor class but the bulk of the service is rendered to the patients on payment basis. The expenses incurred for providing free service are met out of the income from the service rendered to the paying patients. The service rendered by such Doctors and hospitals to paying patients undoubtedly fall within the ambit of Section 2(1)(o) of the Act.

45.   The question for our consideration is whether the service rendered to patients free of charge by the doctors and hospitals in category (iii) is excluded by virtue of the exclusionary clause in Section 2(1)(o) of the Act. In our opinion the question has to be answered in the negative. In this context, it is necessary to bear in mind that the Act has been enacted to provide for the protection of the interests of "consumers" in the background of the guidelines contained in the Consumer Protection Resolution passed by the U.N. General Assembly on April 9, 1985. These guidelines refer to "achieving or maintaining adequate protection for their population as consumers" and "encouraging high levels of ethical conduct for those engaged in the protection and distribution of goods and services to the consumers". The protection that in envisaged by the Act is, therefore, protection for consumers as a class. The word "users" (in plural), in the phrase 'potential users' in Section 2(1)(o) of the Act also gives an indication that consumers as a class are contemplated. The definition of 'Complainant' contained in Section 2(b) of the Act which includes, under Clause (ii), any voluntary consumer association, and Clauses (b) and (c) of Section 12 which enable a complaint to be filed by any recognised consumer association or one or more consumers where there are numerous consumers, having the same interest, on behalf of or for the benefit of all consumers so interested, also lend support to the view that the Act seeks to protect the interests of consumers as a class. To hold otherwise would mean that the protection of the Act would be available to only those who can afford to pay and such protection would be denied to those who cannot so afford, though they are the people who need the protection more. It is difficult to conceive that the Legislature intended to achieve such a result. Another consequence of adopting a construction, which would restrict the protection of the Act to persons who can afford to pay for the services availed by them and deny such protection to those who are not in a position to pay for such services, would be that the standard and quality of service rendered at an establishment would cease to be uniform. It would be of a higher standard and of better quality for persons who are in a position to pay for such service while the standard and quality of such service would be inferior for person who cannot afford to pay for such service and who avail the service without payment. Such a consequence would defeat the object of the Act. All persons who avail the services by Doctors and hospitals in category (iii), are required to be treated on the same footing irrespective of the fact that some of them pay for the service and others avail the same free of charge. Most of the Doctors and hospitals work on commercial lines and the expenses incurred for providing services free of charge to patients who are not in a position to bear the charges are met out of the income earned by such Doctors and hospitals from services rendered to paying patients. The Government hospitals may not be commercial in that sense but on the overall consideration of the objectives and the scheme of the Act it would not be possible to treat the Government hospitals differently. We are of the view that in such a situation the persons belonging to "poor class" who are provided services free of charge are the beneficiaries of the service which is hired or availed of by the "paying class". We are, therefore, of opinion that service rendered by the Doctors and hospitals falling in category; (iii) irrespective of the fact that part of the service is rendered free of charge, would nevertheless fall within the ambit of the expression "service" as defined in Section 2(1)(o) of the Act. We are further of the view that persons who are rendered free service are the "beneficiaries" and as such come within the definition of "consumer" under Section 2(1)(d) of the Act.”

A bare perusal of the above cited ruling of the Hon’ble Apex Court shows that all persons who avail the service by doctors and hospitals in category (iii) are required to be treated on the same footing irrespective of the fact that some of them pay for the service and others avail the same free of charge. It was further held that persons who are rendered free service are the beneficiaries and as such come within the definition of ‘consumer’ under section 2(1)(d) of the consumer Protection Act. The above cited ruling of the Hon’ble Supreme Court was also followed by our own Hon’ble State Commission in Dr. Arvinder Joshi Vs. Rajinder Kumar & Ors., First Appeal No.59 of 2013 decided on 16.7.2013 and it was held that service rendered at a Govt. hospital/health centre/dispensary, where the services are rendered on payment of charges and also rendered free of charge to other persons, availing of such services would fall within the ambit of expression ‘service’ as defined in Section 2(1)(o) of the Consumer Protection Act. Applying the ratio of the above cited rulings, we hold that the complainant falls within the definition of ‘consumer’ and the service rendered by OPs 1 to 4, even if it was rendered free of charge to Mrs. Harjinder Kaur, would fall within the ambit of the expression ‘service’ as defined in Section 2(1)(o) of the Act. 

11.         The next material question for determination is whether the condition of Mrs. Harjinder Kaur deteriorated and she died due to negligence and careless attitude/ deficiency in service of OPs 1 to 4 or the doctors on duty managed the patient as per standard protocols and are not responsible for known complications of pregnancy and its management?  The admit card (Annexure C-1) of the wife of the complainant reveals that at the time of admission on 8.8.2013 in OP-1, her vitals and fetal heart rate were normal.  She had one previous normal vaginal delivery 12 years back.  Her ultrasound examination (Annexure C-2) got conducted from Bharat Vikas Parishad on 8.8.2013 also shows  that a single normal living fetus of approx. maturity 37 weeks 5 days was seen with score 8/8. All the investigations already done in OPD were normal. The treatment record coupled with the written statement of OPs show that a decision for induction of labour was taken by the Gynaecologist and as the Bishop score was poor, cervical ripening with 25 ug of misoprostol was given. On 10.8.2013, patient was shifted to antenatal ward and on that day also she was normal.  The FHS record every 1 hour was normal on 11.8.2013 and even on 12.8.2013.  On 12.8.2013, Dr. Swapanjeet Kaur surgically induced labour by artificial rupture of the membrane and clear liquor was obtained and labour was augmented by starting Pitocin.  On that very day, fetal heart sounds were continuously and adequately monitored by the duty doctors and nursing staff.   At 6:00 p.m., the patient was examined by Dr. Sudha with Dr. Pallavi, the cervix was fully dilated and decision for emergency caesarean section was taken in view of non descent of fetal head.  At 6:30 p.m., the patient’s vitals were normal and intermittent fetal rate slowing was present and the patient was ordered to be shifted to operation theatre but when the trolley was wheeled out of the labour room towards the operation theatre, the patient suddenly collapsed in the corridor. Dr. Pallavi, who was in the Gynaecology emergency examining a patient, immediately rushed towards the CLR and the other senior doctors were also informed.  At that time, the patient was pulseless and BP was also not recordable and she immediately started with CPR, oxygen inhalation, fluid replacement emergency/ cardiotonic drugs etc. but despite the efforts of the doctors, Mrs. Harjinder Kaur could not be revived and was declared dead at 7.55 p.m.  As per the treatment record (Annexure OP-1/3), there was cardio respiratory arrest and the most probable cause was amniotic fluid embolism.  Copy of the postmortem examination report (at page 48 to 50 of the paper-book of the complainant)  shows that in the opinion of the doctors, death was due to shock and hemorrhage due to injury to uterus which was sufficient to cause death in ordinary course of nature. Routine viscera was sent for chemical and histopathological examination. Copy of Histopathological examination by the Govt. Medical College, Sector 32, Chandigarh (Annexure OP-2/2) shows that there were changes gravid uterus with evidence of rupture and amniotic fluid emboli in uterine vessels.  
12.         It is noteworthy that an enquiry into this unfortunate incident was conducted by Dr. Anju Huria, Professor and Head cum Chairman, Department of Obstetrics & Gynae, Govt. Medical College Hospital, Sector 32, Chandigarh and Dr. Soma, District Family Welfare Officer-cum-Member, Sector 22, Chandigarh.  During the enquiry, statements of Dr. Sudha Rani, Dr. Pallavi Pasricha, Dr. Swapanjeet Kaur, Ms. Monika, ward attendant, Mrs. Sudesh, safai karamchari and husband of the deceased etc. were recorded.  As per the conclusion arrived at by the doctors, in the enquiry report, the unfortunate incident which occurred on 12.8.2013 was sudden, catastrophic intraperitoneal bleeding (3-5 liters) which occurred due to rupture uterus.  It was also found by the doctors during enquiry that such a situation the diagnosis of amniotic fluid embolism (AFE) is usually the first possibility. Only in this the death is so unpredictable and sudden. However, during enquiry the following lacunae were noted down in care of patients :-

“From all the above it is obvious that

1.     For 22 beds in labour ward, roughly 38-40 patients are admitted.

2.     Two M.O (MD Gynae) One Senior and One junior came on emergency duty at 2.00 pm.

3.     One House Surgeon (MBBS) is also on duty who sits in the emergency room and makes files and records history etc. in addition to seeing all patients coming to emergency.

4.     These three doctors have to look after the labour ward, emergency Gynae and new admissions. If any admitted and already operated or delivered patient has a problem, they have to leave the labour room to go and examine that patient. They also need to do emergency ultrasound for labouring patients and for this they have to go to the ultrasound room – which is at a distance, is locked and needs to be opened and locked after doing the USG. If a patient requires LSCS or some other surgery – the Senior MO goes to the OT and for the patients in CLR there is only one doctor (MD Gynae).

5.     Although six nurses are on duty, they have different duties assigned to them, and for checking pulse and FHS and to give medicines, injections etc. to the 35-40 patients in the labour room, there is only one nurse.

a)     For 40 patients in the labour ward, only three doctors are available.  Out of these also, practically, the senior MO is in operation theatre whenever a patient is shifted for LSCS. For good patients monitoring, even if a doctor spends roughly 5 minutes with each patient, (checking pulse, FHS, ut contraction, which may take less than 5 minutes, but a patient who requires pelvic examination will take about 10 minutes); she will take 40 x 5 = 200 minutes for taking one round.  That means, that practically, in a labour of 6 hours duration, a patient will be seen once or twice by the doctor.

b)     The care of the labouring patient, including the fetal heart monitoring, pulse and temperature charting is left to the junior most staff nurse.  She also has to distribute medicines and give injections. The fetal heart monitoring by stethoscope, in the best of circumstances, is difficult and cannot be done by a junior staff nurse.

No electronic fetal monitoring device is available in the labour room.

c)      The number of doctors on emergency duty are grossly inadequate.  Patients in labour are at high risk for many potentially devastating and fetal conditions like

        i)      Amniotic fluid embolism

ii)     Obstetric shock pulmonary thromboembolism

        iii)    Placental abruption

iv)    Disseminated Intravascular Coagulopathy

        v)     Preeclampsia – eclampsia

vi)    Acute respiratory distress syndrome.

During delivery, can have sudden problem like traumatic injury, PPH, inversion uterus. For 40 labouring patients, at least 3-4 doctors, excluding the OT team should be present in labour room. The doctors need to be vigilant and updated on practical protocols for resuscitation of patients. For this, periodic training for adult and neonatal resuscitation needs to be imparted.”

A bare perusal of the enquiry report itself establishes deficiency in service on the part of OP-1/Govt. Multi-Speciality Hospital, Sector 16, Chandigarh. For 40 patients in the labour ward only three doctors were available. Out of this, practically the senior MO is in operation theatre whenever a patient is shifted for LSCS. For good patients’ monitoring even if a doctor spends roughly 5 minutes with each patient, he/she will take 40 x 5 = 200 minutes for taking one round that means practically in a labour of 6 hours duration, a patient will be seen once or twice by doctor.  It was also observed that the fetal heart monitoring by stethoscope in the best of circumstances is difficult and cannot be done by a junior staff nurse. The report establishes that no electronic fetal monitoring device was available in the labour room. Number of doctors on emergency duty was grossly inadequate and patients in labour were at high risk for many potentially devastating and fetal conditions like amniotic fluid embolism (which happened in the present case), obstetric shock pulmonary thromboembolism, placental abruption etc. As per the lacunae pointed out in the enquiry report, for 40 labouring patients at least 3-4 doctors excluding the OT team should be present in labour room.  Further the doctors need to be vigilant updated on practical protocols for resuscitation of patients and for this, periodic training for adult and neonatal resuscitation needs to be imparted.

13.         The statement of Dr. Sudha Rani recorded during the enquiry shows that after she advised to prepare the patient for caesarean section due to non descent of head, she left for operation theatre for exploration of hematoma under anaesthesia of another patient, Ms. Kulwinder Kaur.  Dr. Nirlep Kaur was also in the operation theatre. The statement of Dr. Pallavi Pasricha shows that at about 6.15 p.m., she examined the patient, Mrs. Harjinder Kaur and at 6:30 p.m. she ordered to shift the patient to operation theatre immediately and just then she was called by the staff nurse of gynae emergency to see another patient and when she was examining the new patient, she was called by the CLR staff nurse intimating that the patient (Mrs. Harjinder Kaur) had collapsed on the trolley on her way to operation theatre.  Thus, the evidence on record shows that at the time when the patient, Mrs. Harjinder Kaur collapsed, she was not being monitored by a Gynaecologist due to the paucity of the doctors.  After the patient, Mrs. Harjinder Kaur collapsed then all the doctors gathered and Dr. Pallavi Pasricha immediately started CPR, oxygen inhalation, emergency/cardiotonic drugs etc. As we have already observed, as per the lacunae in care of the patients pointed out in the enquiry report, there was no clinical fetal monitoring device available in the labour room. Furthermore, when Mrs. Harjinder Kaur collapsed, Ms. Monika, labour room ward servant called the sister and trolley was pulled to the inside room.  The doctors gathered and they asked her to bring oxygen cylinder and she went to Nursery-2 to bring a cylinder. The statement of Dr. Shabdeep Kaur, house surgeon shows that just after 5 minutes of sending the patient, Mrs. Harjinder Kaur to the operation theatre, at around 6:30 p.m. sister Mandeep called her and told that the patient did not seem to be alright. She went running to Dr. Pallavi and called her up from gynae emergency. She came there and they shifted the patient back to CLR to administer oxygen which was available only in eclampsia room and no cylinder was present in CLR. The ward servant, Ms. Monika was sent to get oxygen cylinder which she brought from Nursery-2 but by that time the doctors and sisters had wheeled the trolley back into the CLR and piped oxygen was used to resuscitate the patient.
14.         Article 47 of the Constitution of India recognizes the improvement of public health as one of the primary duties of the State.  Public health can be improved by having sufficient and best of doctors, specialists and super specialists.  In the instant case, it is quite evident that at the time when the patient, Mrs. Harjinder Kaur collapsed, Dr. Nirlep Kaur was in operation theatre and Dr. Sudha Rani was assisting her because one patient, Ms. Kulwinder Kaur was having a big hematoma and she was bleeding profusely. Dr. Pallavi Pasricha was called to emergency gynae for some other patient. Dr. Shabdeep, house surgeon was M.O on duty and she had checked the pulse, BP and FHS of the patient at 6.15 p.m. and then the attendants and safai karamchari shifted the patient to trolley to take her to the operation theatre. The evidence on record coupled with the observations in the enquiry report shows that there was paucity of staff because though six nurses were on duty, yet different duties were assigned to them and in the labour room there was only one nurse.  There was no clinical fetal monitoring device in the labour room and after the patient collapsed and was brought back to CLR, no oxygen cylinder was present in the CLR. We are of the view that paucity of the doctors and staff, non-availability of the Gynecologist for proper monitoring of the patient, non-availability of oxygen cylinder in CLR and non-availability of the clinical fetal monitoring device in the labour room constitute deficiency in service on the part of OP-1.   The death of Mrs. Harjinder Kaur and the child in her womb might would have been averted had there been no deficiency in service on the part of OP-1 as enumerated above. 
15.         Adverting to the question of negligence/ carelessness on the part of doctors i.e. OPs 2 to 4, as already observed, Dr. Nirlep Kaur and Dr. Sudha Rani were present at the relevant time in operation theatre and taking care of an emergency patient and Dr. Pallavi Pasricha had also gone to emergency gynae to see some other patient.  It is not the case of the complainant that when the patient collapsed, the doctors were gossiping and did not care for the critical patients. Needless to say, taking into consideration the number of doctors available at the relevant time, it cannot be expected that a doctor should be available with every patient.  A doctor is the best judge to decide as to which patient requires his/her attention most out of all the patients.  In the instant case, after the doctors received the message of critical condition of Mrs. Harjinder Kaur, they made all the possible efforts of resuscitating her but unfortunately their efforts turned futile. The complainant has failed to produce any evidence to this effect that the treatment and management of the patient, Mrs. Harjinder Kaur was not as per the standard protocols. It is well settled that onus of proving medical negligence lies on the complainant. Mere averment in the complaint is no evidence and the allegations are to be proved by cogent evidence. The complainant is obliged to provide facta probanda as well as facta probantia as held in C.P. Sreekumar (Dr.), MS (Ortho) Vs. S. Ramanujam, (2009) 7 SCC 130.  In the instant case, the treatment which was given to the deceased was in accordance with the medical practice and there is no such expert opinion from which we could conclude that there was negligent treatment or wrong treatment given to her.  The first line of treatment after collapse was resuscitation and the same was provided immediately by the specialists including Anaesthetist.  Since in the instant case the doctors (OPs 2 to 4) have adopted usual and normal practice which a professional man of ordinary skill would have taken, and there was no negligent or wrong treatment, we are unable to infer any individual medical negligence by the doctors on duty when the patient became critical/collapsed.
16.         Lastly, the histopathological report and the post mortem report of the deceased confirmed that the cause of death of patient was amniotic fluid embolism and postero-lateral uterine rupture. As per the literature by Lisa E Moore, MD, FACOG (submitted by the OPs), amniotic fluid embolism (AFE) is a rare obstetric emergency in which it is postulated that amniotic fluid, fetal cells, hair or other debris enter the maternal circulation causing cardiorespiratory collapse. The learned counsel for the OPs has cited a ruling Addala Veera Venkata Satyanarayana Vs. Dr. Smt. V. Sarojini, F.A. No.756 of 2007 decided on 6.10.2010 by the Hon’ble A.P. State Commission at Hyderabad which relates to amniotic fluid embolism.  In that case, the complainant claimed a sum of Rs.10,00,000/- towards damages on the premise that the OP had not properly attended the patient and left the patient to the care of unqualified nurse. The Hon’ble A.P. State Commission after appraising the evidence made the following observations :-

“The extract downloaded from internet on Amniotic Fluid Embolism by the complainant shows that it is more likely a male fetus is the cause and the condition is considered an unpredictable and unpreventable event, and the cause is reported as unknown.  It is mentioned in cause for Perpnea Maternal Death that Amniotic Fluid Embolism is a rare but fatal complication of labour in which Amniotic Fluid Embolism factors the maternal vascular system becomes lodged in the pulmonary vascular bed.  The signs and symptoms of Amniotic Fluid Embolism are followed with respiratory distress followed by cyanosis followed by cardiac vascular collapse followed by hemorrhage.  The oppose party has attended to Amniotic Fluid Embolism as most of the symptoms referred to by the complainant were present in the patient, she had administered cardiac massage, dopamine drip, adreline injection and dextrose.  

Therefore, all possible measures were taken by the opposite party to revive the patient which however could not save the life of the patient.  The loss of life of the patient by itself will not be construed as negligence in treatment administered by the opposite party while the patient was attacked by Amniotic Fluid Embolism in the labour room in the hospital…….” 

The learned counsel for the OPs has also cited a ruling K. Surender Reddy & Anr. Vs. Gemini Nursing Home & Anr., C.C. No.26 of 2008 decided on 30.8.2011 by the Hon’ble A.P. State Commission at Hyderabad, wherein the medical literature excerpted from Wikipedia was reproduced as below :-

“9)    In the medical literature excerpted from Wikipedia it was mentioned :

Amniotic fluid embolism (AFE) is a rare and incompletely understood obstetric emergency in which amniotic fluid, fetal cells, hair, or other debris enters the mother's blood stream via the placental bed of the uterus and triggers an allergic reaction. This reaction then results in cardiorespiratory (heart and lung) collapse and coagulopathy. It was first formally characterized in 1941. It is the fifth leading cause of maternal mortality.

once the fluid and fetal cells enter the maternal pulmonary circulation in general terms there will be profound respiratory failure with deep cyanosis and cardio vascular shock followed by  convulsions and profound coma, however this does occur in two phases detailed below:

First phase The patient experiences acute shortness of breath and hypotension. This rapidly progresses to cardiac arrest as the chambers of the heart fail to dilate and there is a reduction of oxygen to the heart and lungs. Not long after this stage the patient will lapse into a coma. While previously believed to have a maternal mortality rate of 60-80%, more recently it has been reported at 26.4%.

Second phase Although many women do not survive beyond the first stage, about 40 percent of the initial survivors will pass onto the second phase. This is known as the hemorrhagic phase and may be accompanied by severe shivering, coughing, vomiting, and the sensation of a bad taste in the mouth. This is also accompanied by excessive bleeding as the blood loses its ability to clot. Collapse of the cardiovascular system leads to fetal distress and death unless the child is delivered swiftly.”

In the above noted case also, no negligence was inferred on the part of the doctor while conducting delivery. 

17.         As held in the above cited rulings, Amniotic Fluid Embolism is a rare but fatal complication of labour in which Amniotic Fluid Embolism factors the maternal vascular system becomes lodged in the pulmonary vascular bed. After scrutinizing the entire evidence and applying the ratio of the above cited rulings, we do not find any negligence or carelessness on the part of the doctors i.e. OPs 2 to 4.   In the instant case, all possible measures were taken by the OPs 2 to 4 to revive the patient which, however, could not save her life.  However, as already observed, there is deficiency in service on the part of OP-1/institution in view of the observations made in the enquiry report conducted by Dr. Anju Huria and Dr. Soma.
18.         For the reasons recorded above, we find merit in the complaint and the same is partly allowed qua OP-1. 
    OP-1 is directed :-

(i)     to pay a compensation of Rs.1,50,000/- to the complainant for deficiency in service and causing mental agony and physical harassment to him.

(ii)    to pay litigation costs to the tune of Rs.10,000/- to the complainant.

19.         This order be complied with by OP-1 within one month from the date of receipt of its certified copy, failing which it shall make the payment of the amount mentioned at Sr.No.(i) above, with interest @ 12% per annum from the date of filing of the present complaint till realization, apart from compliance of direction at Sr.No.(ii) above.
20.         The complaint fails against OPs 2 to 5 and is dismissed with no order as to costs. 
21.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd//-
13/07/2015	[Suresh Kumar Sardana]	[Surjeet Kaur]	[P. L. Ahuja]
hg	Member	Member	President