ASWATHNARAYANA vs B.ANUSUYA

OFTEN we are coming across cases where several private Hospitals do not have basic facilities, such as intensive care unit, sufficient medical staff round the clock, blood bottles and other infrastructure in the hospital. If these facilities are not provided in time, a patient may die. Hospitals should concentrate on providing better treatment rather than on making money. In the case on hand a lady who had gone to a private hospital for delivery died because of lack of basic infrastructure in the hospital and also due to negligence on the part of the doctor.

THE complainant has filed this complaint claiming compensation of Rs. 25,00,000 from the opposite parties (for short, "O.Ps.") alleging "negligence" and "deficiency in service" on the part of the O.Ps. The brief facts of the case of the complainant are that his wife Smt. Vishalakshmi (for short, the "patient") was admitted to Pragathi Hospital at Tumkur, which is run by the O.Ps., on 27.12.1999 for delivery. O.P. 1 on examination advised the patient to go for caesarean section (LSCS) for giving birth to a child and, accordingly, O.P. 1 conducted caesarean section after administering spinal anaesthesia by O.P. 2 and the patient gave birth to a female child at 8.40 p.m. on 27.12.1999 in the said hospital. On the very night of the delivery, according to the complainant, the patient started gasping for breath and the medical staff which attended to the patient found that her blood pressure was low and she had irregular heart beats and her abdomen had distended. The complainant after coming to know of the said fact on 29.12.1999 rushed to Tumkur on 29.12.1999 and requested the O.Ps. to seek expert advice after he came to know that the O.Ps. had been negligent in discharge of their duties. As there was no intensive care unit or ventilator support in the Pragathi Hospital, the complainant requested the O.Ps. to get the patient immediately discharged and, accordingly, the patient was discharged and was brought to Bangalore in an Ambulance and she was taken to Vijayanagar Nursing Home, Vijayanagar, Bangalore. In that Hospital, the doctor on examination advised the complainant to take the patient to a well-equipped Hospital as he was of the opinion that the patient''s problem might be due to septic-shock. Accordingly, the patient was shifted to Mallige Hospital on the very same day in the very same Ambulance. In the Mallige Hospital after conducting a detailed inquiry and medical tests it was found that the right inferior epigastric artery of the patient had given way leading to internal bleeding which resulted in large collection of blood in the abdomen. The doctor who conducted the surgery in the Mallige Hospital informed the complainant that the right inferior epigastric artery was cut during caesarean operation and had not been sutured after the operation and this had resulted in large collection of blood in the abdomen leading to its distension. This internal bleeding resulted in loss of supply of blood to various vital organs of the body, which resulted in breakdown of these organs. Thereafter the patient was put in intensive care unit/ventilator. Then the patient was taken to M.S. Ramaiah Hospital, Bangalore, where she underwent ''Haemo-Dialysis''. Ultimately, the patient was shifted to Manipal Hospital on 6.1.2000 and in the said hospital she was put to certain tests with ventilator support system. Despite these measures, the patient died on 14.1.2000 due to ''septic multi organ failure''.

According to the complainant, if O.P. 1 had taken proper care while conducting caesarean section she could have noticed the bleeding from the right inferior epigastric artery and she could have legated the same and thereby saved the life of the patient. This, according to the complainant, is a sheer negligence on the part of O.P. 1 in not noticing that the right inferior epigastric artery was cut. In addition to this, there was "deficiency in service", as proper service as required to be provided by an ordinary doctor was not provided.

ACCORDING to the complainant, the patient was aged 30 years as on the date of her death and she died leaving behind him and two children. Further, he has also spent considerable amount for her treatment both at Tumkur and Bangalore in various hospitals. Therefore, he is entitled for a compensation of Rs. 25,00,000 from the O.Ps. The O.Ps. have filed their version. In the version they admit that the patient was admitted in their Hospital called ''Pragathi Hospital'' for delivery. The O.Ps. also admit that the patient delivered a female baby on 27.12.1999 through caesarean section. But they dispute the allegation of negligence made against them. O.P. 1 is a gynaecologist and O.P. 2 is an anaesthetist. The caesarean section was conducted by O.P. 1 after administering spinal anaesthesia by O.P. 2. According to O.P. 1 the right inferior epigastric artery was cut while doing the caesarean section and if at all there was any bleeding the same must have occurred at the time of re-opening of the wound in the Mallige Hospital at Bangalore. According to the O.Ps., the condition of the patient was normal and there was no bleeding as per the Scanning report conducted at Tumkur and the post-operative complications developed in the patient due to ''Pancreatitis'' as she had taken treatment for the said disease earlier. According to the O.Ps., the patient had not disclosed that the first delivery was also through caesarean section when she was admitted to their Hospital and, therefore, all post operative complications developed due to non-disclosure of the fact of earlier caesarean section and the earlier treatment of Pancreatitis taken by the patient. The sum and substance of the version filed by the O.Ps. is that there was no negligence on their part in conducting the caesarean section.

BEFORE dealing with the rival contentions of the parties, it is relevant to refer to the order dated 29.1.2001 passed by the Karnataka Medical Council (for short, "KMC") on the complaint filed by the complainant. In the said order the KMC has held that the complainant has established negligence on the part of O.P. 1. A copy of the said report has been produced by the complainant. All the parties have filed their affidavits by way of evidence in support of their case. The parties were also subjected to cross-examination. Both the complainant and the O.Ps. have produced documents in proof of their case, which are marked as exhibits. On the rival contentions of the parties referred to above, the following points arise for consideration: (1) Whether the complainant establishes the negligence on the part of the O.Ps. as pleaded in his complaint? (2) To what relief the complainant is entitled?

POINT No. 1: It is not in dispute that the patient was admitted to Pragathi Hospital at Tumkur, which is run by the O.Ps., for delivery of a second child on 27.12.1999. It is also not disputed that the delivery of baby was through caesarean section. The patient gave birth to a female baby on the very same day at about 8.40 p.m. According to O.P. 1, the operation was successful and, therefore, she informed the relatives of the patient that the patient gave birth to a female baby and that the mother and the baby were normal. According to the complainant the patient started gasping for breath in the very same night and the medical staff which attended to her found that her blood pressure was low and she had irregular heart-beats. The hospital records produced by the O.Ps. disclose that the blood pressure and other things were normal after the operation but there was a distension of the stomach and, consequently, the patient developed post-operative complications. According to the O.Ps., though the O.P. Hospital is a well-equipped Hospital, as it did not have intensive care unit/ventilator, they advised the complainant to take the patient to a major hospital at Bangalore. According to the complainant also as he found that there was no infrastructure in the O.P. Hospital, he requested O.P. 1 to discharge the patient in order to take her to Bangalore. Accordingly, the patient was discharged on 29.12.1999 and immediately thereafter the patient was brought to Vijayanagar Nursing Home, Vijayanagar, Bangalore. In the said Hospital one Dr. Ravindra Alur examined the patient and as he found that the condition of the patient was serious and the blood pressure and pulse were not recordable, he advised the complainant to take the patient to Mallige Hospital. A copy of the reference letter dated 29.12.1999 given by Dr. Ravindra Alur is produced as Exhibit ''C-16''. On his advice the patient was shifted to Mallige Hospital at Bangalore. In the said Hospital, one Dr. S.P. Bellani, Surgeon and Dr. Beena Vasan, Gynaecologist conducted Laporatomy procedure. They legated the right inferior epigastric artery and evacuated large collection of blood. Ultimately, as there was a failure of multi organs, the patient was taken to M.S. Ramaiah Hospital, where she underwent Haemo-Dialysis and, ultimately, she was shifted to Manipal Hospital. In Manipal Hospital also several tests were conducted. But, unfortunately, the patient died on 14.1.2000 at Manipal Hospital due to Septic Multi Organ Failure.

THE complainant has filed his affidavit by way of examination-in-chief. What is stated by him in the affidavit is almost a repetition of the averments made in the complaint. THE complainant was also cross-examined by the Advocate appearing for the O.Ps. In the cross-examination he has stated that the scanning and medical tests were conducted in Mallige Hospital. THE discharge summary issued by the Mallige Hospital is marked as Exhibit ''C-13''. THE complainant has also spoken to the contents of the said discharge summary. In the said discharge summary issued by the Mallige Hospital it is observed as follows: "Course : Same day patient was taken to O.T. for Laporatomy and procedure where they found right inferior epigastric artery bleed which was legated and large collection of blood evacuated by Dr. Belani (Surgeon) and Dr. Bina Vasan (Gynaecologist). Later post procedure patient was put on ventilator support and was on following medications: IV Myticef (7 days), IV Metrogyl (7 days), IV Dopamine drip, Blood Transfusion since her Hb% was 6.6 gm% with CVP monitoring. Renal function test were found deranged (29.12.99) BUN - 39 mg/d1, Creatinine - 3.8 mg/d1 for which Dr. Umesh (Nephrologist) was consulted who diagnosed it to be acute renal failure due to hypovaslumai and advised to give IV Lesix 160 mg with amikacin 500 mg state and to maintain DVP at 10 cms of water. Later on 4.1.2000 patient was given haemodialysis at M.S. Ramaiah Hospital following which she had 1 episode of generalised tonic clonic seizures which Dr. B.P. Mruthyunjayanna (Neuro Physician) diagnosed as 7 cerebral venous thrombosis 7 ureamic seizures, 7 pulmonary embolism. On 4.1.2000 X-ray Chest showed collapse consolidation left lung - hence was again put on ventilator, IV Myticef was stopped and IV Cafraom, IV Tarivid, IV Epsolin were started, IV Gardenal, IV Glexane 400 mg. 1-0-1. On 6.1.2000 patient on ventilator with sedatives, Pulse - 136/min, B.P. - 120/90 mmHg, 02 Sat - 100%, CVP - 8 cms of H20, Patient shifted to Manipal Hospital for dialysis and further management."

From a reading of the above discharge summary it is seen that the patient was taken to Operation THEatre for Laporatomy. Dr. Belani (Surgeon) and Dr. Bina Vasan (Gynaecologist) found that the right inferior epigastric artery was continuously bleeding and they legated the same and evacuated the large collection of blood. The order dated 29.1.2004 passed by the KMC on the complaint of the complainant has been produced in this case by the complainant. From the said order it is seen that the complainant had filed the complaint against O.P. 1 on 22.6.2000. Prior to filing of the said complaint, the complainant has filed the present complaint before this Commission on 26.5.2000. During the pendency of the present complaint, the KMC has passed the above said order on 29.1.2004. From the said order it is seen that Dr. S.S. Belani, Dr. Bina Vasan, Dr. Mahesh Kukreja, Dr. Ravindra, Dr. Anusuya and Dr. Srinivas gave their evidence before the KMC. After filing of the said order before this Commission the O.Ps. have not disputed or denied the fact that the above said doctors gave evidence before the KMC. The O.Ps. also have not disputed the correctness of the statement of the above said doctors. No doubt the evidence given in one case cannot automatically be treated as evidence in another case. But in the absence of dispute as stated above, there is no reason to discard the statement made by the above said doctors before the KMC. Dr. Belani who conducted the second surgery has stated before the KMC as follows: "Findings - Large Blood Clot between Rectus Sheath and Peritonium - Pelvis was full of blood. Right inferior epigastric artery was seen bleeding continuously which was ligated. No ligature material was seen over the inferior epigastric artery. The source was the artery which was legated. Moderate collection of blood in Pelvic Cavity - condition improved. She went into ''Renal Failure on 30.12.1999. Patient was discharged on 6.1.2000 at 9.10 a.m. Acute tubular necrosis earlier intervention would have been better."

Dr. Bina who is a Gynaecologist and who was present at the time of the second surgery in Mallige Medical Centre has stated as under: "...On opening the suture line we found 3 ltr Blood Clot between the rectus sheath and peritoneum. Removed the clot-found inferior epigastric artery was bleeding legated the vessel 200 cc collection in the pouch was douglas. Peritoneal lavage etc., was done closed the abdomen."

O.P. 1 in her statement before the KMC has stated as follows: "I suspected internal bleeding. P.V. Normal bleeding. Abdomen soft, Gaseous distension present. She had suffered acute pancreatitis 10 months ago. A physician was called. Suspected pancreatitis."

O.P. 2 has stated before the KMC as follows: "...If they had taken early decision. Patient would have been saved." On examination of the evidence, the KMC recorded a finding as follows: "Karnataka Medical Council is of the opinion that there was negligence on the part of Dr. B. Anusuya which has been established beyond doubt."

O.P. in her version and in her evidence has stated that the post-operative complications developed due to earlier treatment for pancreatitis and, therefore, she suspected that the patient was suffering from Pancreatitis and, accordingly, she referred the patient to a major hospital for treatment for pancreatitis. As referred to earlier, O.P. 1 has stated before the KMC that she suspected internal bleeding. The scanning report conducted at Tumkur did not disclose any internal bleeding. But when O.P. 1 suspected internal bleeding she could have taken steps to find out the cause for internal bleeding or she could have referred the patient immediately to some major hospital for treatment. In the instant case, though the complications developed in the very night after the caesarean section, the patient was shifted to Bangalore after two days, i.e., on 29.12.1999.

ADMITTEDLY, when the patient was admitted for delivery, there was no complaint of bleeding of right inferior epigastric artery. As per the report of the Mallige Hospital, the bleeding was because of cut of right inferior epigastric artery. The cut of right inferior epigastric artery necessarily was only at the time of conducting the caesarean section as there was no such complication earlier. If O.P. 1 had noticed the cut of right inferior epigastric artery before suturing, then there would not have been any scope for further complications. In the instant case, it appears O.P. 1 before suturing did not examine whether there was cut of any other organ. O.P. 1 no doubt has stated in her affidavit that the bleeding from the right inferior epigastric artery was because of non-legation or it may be due to one of the post operative complications or repeated examination of the abdomen or rough handling of the wound or it would have happened at the time of re-opening the same. In support of this statement O.P. 1 has not produced any evidence before this Commission. O.P. 1 in her cross-examination stated that the stomach of the patient was not distended, whereas O.P. 1 who was examined as R.W. 2 in his cross-examination has stated that on 29.12.2000 at about 12.30 a.m. there was a call and he went and saw the patient and he noticed that the abdomen of the patient had distended. From this it is seen that the evidence of O.P. 1 is inconsistent with the evidence of O.P. 2. O.P. 1 has stated that if the inferior epigastric artery is not sutured it will ooze out blood. From the discharge summary issued by the Mallige Hospital it is seen that the right inferior epigastric artery was cut and the same was legated and large collection of blood was evacuated. The same thing was stated by the Surgeon who conducted the second surgery before the KMC. Relying upon the said discharge summary we find that O.P. 1 while conducting caesarean section had cut the right inferior epigastric artery and the same was not noticed by her before suturing. If at all if O.P. 1 had noticed the cut, in all probability the same could have been legated by her and in that event the life of the patient would have been saved. The O.Ps. in their version have stated that the patient and the complainant did not disclose that the first delivery was through caesarean section. In fact, the first delivery was also in the very same Pragathi Hospital which is run by the O.Ps. If that were to be the case, there was no reason for the O.Ps. to blame the complainant on the ground that the complainant and the patient had suppressed the fact of earlier caesarean section as it was within their knowledge. In the instant case, there was no complaint of any injury to the pancreas prior to the caesarean operation. Further there was no scope for any injury to pancreas while doing caesarean section since according to O.P. 2 the distance between the pancreas and right inferior epigastric artery is about 6" and according to O.P. 1 the distance is about 10", whereas the right inferior epigastric artery is very close to the area where the caesarean section was conducted. It is also a case where the maxim ''res ipsa loquitur'' is applicable because earlier to the caesarean operation there was no complaint of any bleeding. The bleeding was because of cut of right inferior epigastric artery subsequent to the caesarean operation. The fact that the bleeding was due to cut of right inferior epigastric artery has been spoken to by the doctor who conducted the second surgery in Mallige Hospital. Therefore, we are of the view that the internal bleeding was because of the negligence on the part of O.P. 1 is not noticing the cut of right inferior epigastric artery.

HENCE, we are of the considered view that the complainant has established the "Negligence" and "Deficiency in Service" on the part of O.P. 1 while doing caesarean section. Admittedly, Pragathi Hospital run by the O.Ps. did not have intensive care unit/ventilator. When the O.Ps. undertake surgery, necessarily these facilities should have been made available in the very Hospital. But, unfortunately, there was no such facility in the said Hospital. Therefore, we are of the view that lack of infrastructure in the Hospital does amount to "Deficiency in service". Hence, we answer point No. 1 in the affirmative. Point No. 2 : The complainant has established the "Negligence" and "Deficiency in service" on the part of the O.Ps. as pleaded in his complaint. Therefore, the complainant is entitled for compensation. According to the complainant he has spent lot of money for the treatment of his wife at Tumkur and Bangalore in various Hospitals. But no bills have been produced by the complainant before this Commission. It is stated that the patient was working as a lecturer in a College and was drawing salary of Rs. 15,000 per month. But no evidence has been produced in this regard. The patient was aged about 30 years at the time of her death. She died leaving behind two minor children. The complainant is also deprived of her companionship. Therefore, taking all these facts into consideration, we are of the view that awarding a sum of Rs. 2,00,000 as compensation in favour of the complainant would meet the ends of justice.

IN the result, we pass the following order: (1) The complaint is allowed in part. (2) The O.Ps. are directed to pay jointly and severally Rs. 2,00,000 (Rupees two lakhs only) to the complainant within two months from today. (3) IN the event if the O.Ps. fail to pay the amount within two months as directed above, the O.Ps. are liable to pay interest at 6% per annum on the said sum of Rs. 2,00,000 from the date of the complaint till realization. (4) Since the patient died leaving behind two minor children, the complainant is directed to deposit the above said sum in the name of the minor children in a Nationalized Bank till they attain majority. However, the complainant is permitted to withdraw the interest on the said sum for the purpose of education and other necessities of the minor children. (5) The O.Ps. are also directed to pay Rs. 5,000 (Rupees five thousand only) to the complainant towards the costs of these proceedings.

OFFICE to send a copy of this order to the Secretary to Government, Department of the Health and Family Welfare Services of the Government of Karnataka. We hope the Government will lay down guidelines with regard to the basic infrastructure/facilities to be provided in every private Hospital and to conduct periodical checks and take action against erring Hospitals, so that lives of innocent patients are not taken away by the Hospitals for lack of basic infrastructure in the Hospitals. Complaint partly allowed.