New Delhi: The District Consumer Disputes Redressal Commission, New Delhi recently directed a city-based hospital and its doctors to pay Rs 48 lakh to a man who lost his wife due to alleged medical negligence by the treating hospital and its doctors. While the gynaecologist at the hospital was held guilty of undertaking the surgery (Diagnostic and Operative Hysteroscopy) without the necessary skills, the hospital was held liable for laxity in not ensuring the proper documentation of the events, progress notes, nursing notes and reports of the diagnostic tests and for manipulating and withholding the same. Another doctor at the hospital was held liable for uan nethical partnership with the gynaecologist and the hospital in manipulating the medical records
The history of the case goes back to 2013 when the patient was admitted to the city-based hospital to be operated on for Asherman’s Syndrome by Diagnostic and Operative Hysteroscopy +D&C. The complainant, husband of the patient, was informed that the patient had developed some complications. After a few minutes, the doctors informed that they were unable to handle the complications developed during the surgery and for this, they were shifting the patient to Fortis Escorts Hospital, where the patient breathed her last.
Although the hospital claimed that the deceased had a cardiac arrest during surgery when the hysteroscope was being removed from the uterine cavity, the complainant claimed that the patient’s condition could not be managed in the operation theatre itself due to the lack of expertise, proper assessment, absence of specialist doctors and required machines etc. resulting into prolonged cardiac arrest without proper resuscitation.
The complainant also referred to the death summary prepared by Fortis Hospital, which mentioned that the cause of death was not due to cardiac reasons, but it was a case of suspected air embolism. In this regard, the complainant alleged that before the surgery, the doctors did not explain to them about any possibility of any complications of ‘air embolism’. Therefore, he claimed that the patient had died due to the medical misconduct and gross negligence of the treating hospital and doctor.
It was submitted that Fortis Hospital admitted that the X-ray of the chest showed bilateral haziness quite possibly due to aspiration of secretions and that suctions were not done properly at the first hospital or later during transit by Ambulance. By the time, the patient reached the Fortis Hospital, the endotracheal tube was full of bloody secretions which were removed by Suction. Further, the ‘Arterial Blood Gas’ report suggested that the patient was brought to Fortis Hospital in nearly irreversible and dead condition.
On the other hand, the treating hospital and its doctors denied negligence on their part and they also relied on the fact that the Delhi Medical Council did not find any negligence or misconduct on the part of the doctor and hospital. When the complainant appealed against the medical council order, the same was rejected by the erstwhile Medical Council of India.
While considering the matter, the District Commission noted that the hospital and doctor did not provide any evidence to establish any or what and when the medical record was provided to the complainant or Fortis Hospital. Further, the consumer court took note of the contradictory claims regarding the doctor who performed the surgery.
After considering the evidence on record, the Commission observed that either the hysteroscope was not sufficiently state of the art or Dr. Bansal who performed the surgery was not skilful enough to instruct her team and to handle the measures to prevent the entry of the air into the uterine cavity and also to perform hysteroscopy.
“The narration of the anesthetist in the anesthesia notes clearly mentions that the surgeon not only saw the air bubbles in the uterine cavity, but also shouted to “his team” whether air has gone inside, and after which, the hysteroscope was abruptly withdrawn by the surgeon. Also, the cardiac event which occurred in the OT is stated to have been reversed in as much as the patient was resuscitated and the heart condition has been noted by Fortis Hospital to be normal (EF 60% and RA/RV normal and no regional wall motion abnormalities and no evidence of pulmonary evidence, as noted by Fortis Hospital),” noted the Commission.
“In that scenario, how and what event led to the fact that the endotracheal tube had “blood coloured frothy secretions” despite aspiration of 50 ml blood by the anesthetist and why “copious amounts of frothy expectorations” were required to be suctioned off, the ET at regular intervals in OP-2 as also in Fortis Hospital, has not at all been attempted to be explained by the OPs. Also, while Fortis Hospital has noted that the X-ray showed that “patient had chest creps and bilateral diffuse opacities with persistent hypoxemia and mixed acidosis”. By 8.18 am, the patient had already suffered the episode and had been resuscitated, still however, the patient could not be shifted to Fortis hospital before 9.55 am. The explanation for delay and detailed consultation and progress notes as to which diagnostic tests were carried out and what diagnosis were arrived at and what treatment/management was provided is not brought on record by the OPs. As a matter of fact, which particular condition after the patient was resuscitated required the shifting to a “higher center” has also not been explained,” it further observed.
The District Commission noted that a lot of stress had been put by the treating hospital and doctors on the fact that “air embolism” was a likely complication of hysteroscopy.
“However, it is not explained how not random and small quantity of air bubbles but copious amount of air of “beyond tolerance limit” could enter the uterine cavity so as to generate visible air bubbles in the uterine cavity and continuous frothy expectoration in the Endotracheal Tube as has been noted by Fortis hospital,” noted the Commission.
It also observed that the cause of death as noted in the Death Summary was acute pulmonary edema (non-cardiogenic), persistent hypoxemia and severe mixed acidosis which were noted by Fortis Hospital also at the time of admission at 10 am immediately after admission and after 2D Echo reports were received.
“In view of these facts, and on account of absence of any credible and independent and contemporaneous document of diagnostic tests, results and management in the light of such diagnostic findings which could support the version of the OPs that the “suspected air embolism” which happened was only a chance outcome, and that the same happened despite necessary precautions, and that Dr. Sandhya Bansal possessed necessary training, skill and experience in hysteroscopy, we have no option but to hold that the surgery has been performed with less than requisite skill and expertise expected of the surgeon undertaking the hysteroscopy,” the District Consumer Court observed.
Apart from this, the Commission also took note of marked contradiction in the versions of Dr. Bansal and Dr. Manchandra regarding when the actually cardiac arrest was noticed. While Dr. Manchanda maintained that the patient suffered cardiac arrest immediately after the surgery was successfully completed, Dr. Bansal, as supported by Dr. Kapoor, stated that the surgeon had first noticed air bubbles in the uterine cavity and just when the hysteroscope was being “immediately withdrawn”, the patient suffered a cardiac arrest.
“It is therefore very likely that the fluid irrigation and similar measures for securing the uterine cavity against air inflow during surgery was also not skillfully handled or managed,” the Commission noted at this outset.
“While Dr. *** Bansal has maintained that she was not present in the OT, Dr. Manchanda in his reply has stated that Dr. ***Bansal was very much present during the whole of the surgery. Who actually took the decision to shift the patient and what is the basis of this decision has not at all come on record. Further, at the time of admission in Fortis Hospital, the patient had severe “metabolic acidosis and pulmonary edema”. There is no evidence of the progression and management of the patient leading to this stage. All these factors equally point to inept handling and management of the patient,” it further observed.
Although the Commission agreed with the hospital and the doctor, based on the medical literature, that complications of air-embolism can occur during or immediately after the hysteroscopy, it also noted, “when the event has happened in the OT, within the special, exclusive and expert knowledge of the Medical Professionals, the mere doctored documents of complication and literature supporting such likely complications would not be sufficient. The Hospital and the professionals must establish, in such peculiar circumstances, primarily through contemporaneous record of parameters as noted on various monitoring equipments in the OT, diagnostic test-results, and progressive treatment notes of treating experts, that the particular precautions keeping in mind the likely complications were taken and that the patient was managed expeditiously and as per prescribed protocols. For example, the air-embolism is more likely in trendelenburg position, and irrigating systems need efficient management. In expert hands, the complication is least likely. The reason for frothy secretions in endotracheal tube need to be investigated and treated.”
Accordingly, the Commission held Dr. Bansal guilty of medical misconduct and negligence in undertaking the surgery without the skill necessary for surgery and for ensuring that the requisite tests, pre-medication and insulation against likely risk of air embolism, could be provided by her or her team. It also noted that there was no evidence that the hysteroscope used by her for the surgery was state-of-the-art.
The hospital, where she had professed to be the consulting gynaecologist, was held vicariously liable for the negligence of Dr. Bansal. The hospital was also held liable for laxity in not ensuring the proper documentation of the events, progress notes, nursing notes and reports of the diagnostic tests and for manipulating and withholding the same.
Further, the Commission held Dr. Manchanda for unethical partnership with Dr. Bansal and the hospital in manipulating the medical records. However, the Commission exonerated another doctor- Dr. Kapoor after noting that there was no categorical allegation or evidence of any lack of skill or lapse on the part of the doctor.
Accordingly, the Commission ordered, “OP-1 Dr. Sandhya Bansal and OP-2 Bansal Hospital are jointly and severally held liable for payment of compensation of Rs.40 lakhs along with interest at 6% from the date of filing of the complaint till the actual date of payment. OPs-1 and 2 are also liable to pay Rs. 1 lac towards expenses for last rites and medical-bills. OP-3 Dr. Rahul Manchanda is also liable to pay Rs.5 lac as compensation to the complainants with interest at 6% from the date of filing of the complaint till the actual date of payment. OP-1 and 2 shall also pay total cost of Rs.2 lakhs to the complainants. The compliance shall be made within a period of three months.”
To view the order, click on the link below:
https://medicaldialogues.in/pdf_upload/rs-40-l-compensation-256436.pdf
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