Bibekananda Panigrahi vs Prime Hospitals Ltd. and Ors.

"The doctor/patient relationship is at a crossroads. Some patients want the doctor calling all the shots, deciding the best treatment path to follow. Patients miss the trust and warmth found in the personal bond with a caring, competent physician. Boundaries in the doctor -patient relationship is an important concept to help health professionals navigate the complex and sometimes difficult experience between patient and doctor where intimacy and power must be balanced in the direction of benefiting patients."

THE complainant, Mr. Bibekananda Panigrahi took his father, (since deceased, hereinafter referred as ''patient'') was operated by Dr. Maheshwar Sahoo, (OP -2) at Prime Hospital (OP -1), for acute appendicitis. The operation was performed on 5.6.2006 and stitches were removed on 16.6.2006. Unfortunately, the surgical wound showed gapping with pus discharge. Therefore, the patient was made to stay in the hospital for few more days, for dressing. The wound got worsened. Even after 15 days i.e. on 30.6.2006, OP 2, with other doctors, investigated the patient, thoroughly, but was unable to diagnose the cause of infection. The OP -2 gave assurances that it would be cured soon. Then, the patient developed fecal fistula, hence, daily, thrice, dressings was done and costly injections were given. The patient was diabetic and it was under control by insulin, but the OP increased the dose of insulin, considerably. None attended the patient during these sufferings. Thereafter, on 27.07.2006, patient was shifted to nearby Link Poly Clinic and Nursing Home, where the OP 2 assured to visit regularly, but the condition of patient further deteriorated. Hence, on 3.8.2006, the patient was shifted to the SCB Medical College, where the Professor of Surgery opined that the patient was a victim of mistake, committed by the OP -2, which developed post operational multiple complications. Patient was again operated at SCB Medical College. It was found that, many internal wounds were not taken care properly by the OP -2. The patient died on 12.9.2006. Complainant alleged that, the OP -2 had performed wrong operation due to which patient suffered fecal fistula and subsequent complications caused the death of the patient. Hence, the complainant filed a complaint before the State Commission and prayed for compensation of Rs. 26,50,000/ - from the OPs. The State Commission dismissed the complaint. Hence, the complainant approached this Commission by way of this first appeal.

WE have heard learned counsel for both the parties. Learned counsel for the complainant vehemently argued that the patient had appendicitis, which could be treated by medicines. The operation was not performed properly by the OP -2. Therefore, the patient developed fecal fistula, subsequently suffered septicemia and thereafter passed away. It was total negligence on the part of OPs.

THE argument adduced on behalf of OP 2 was that patient was a school classmate and close friend of OP -2 and every care was taken to treat him. The patient had severe gangrenous appendicitis, which was carefully operated. The gaping wound was not due to any negligence on the part of OP, but it was due to delayed healing process. There was no lapse either in the treatment or in post operative care also. The patient was treated for 45 days. The patient took discharge on his own and went to SCB Medical College. Hence, there was no negligence on the part of hospital and doctors. We have perused the medical record on the file. In the history recorded by OP, that the patient had high grade fever and noticed lump in right iliac fossa.(RIF) Hence, the decision was taken for appendectomy. The operative notes clearly reveal that abdominal wall was opened by right para median incision. There was pyo - peritoneum i.e. pus in peritoneal cavity. Appendix was gangrenous and in para coecal position. The base of the appendix was tied up after removing the gangrenous appendix. There was also pus in the sub -hepatic space on right side. Post operatively, the patient was treated with higher antibiotics, like Amikacin, Sulbactum and metrogyl. After removal of stitches, there was gaping of wound with pus discharge. The patient developed fecal fistula.

THE OP managed the post -operative fecal fistula and the infection caused by higher antibiotics. OP further consulted endocrinologist to control the diabetes with dose of insulin. The patient had high blood urea and creatinine. Hence, he consulted a Nephrologist and was treated accordingly. To improve anemia and hyperproteinemia, by blood transfusion IV, parenteral Intravenous proteins and vitamins were given. As there was low output fistula, dressing of the wound was done 3 -4 times per day to keep the wound clean and dry.

IT should be borne in mind that the patient was presented with acute appendicitis of about four days duration. Patient had temperature 102 § F, ultra -sonographically mass was confirmed in RIF and it was apprehended that patient may develop further complications like perforation and gangrenous appendix peritonitis. The patient''s blood sugar at the time of admission was 210 mg% and the kidney functions were disturbed as blood urea was 91 mg and Creatinine was 4.8 mg%, the values were very high. The patient had hypertension and was on medication since last 10 years. We hesitate to apply the doctrine of res -ipsa -loquitur, in this case, as the development of fecal fistula was a sequel of appendicular abscess or gangrenous appendicitis. The patient was diabetic; it was the additional cause for poor healing of wound.

WE have gone through medical literature and several books on surgery like Abdominal Operations by Maingot''s, Text Book of Surgery by Davis -Christopher, Text Book of Operative Surgery by Eric L. Farquharson, Short Practice of Surgery by Bailey & Love''s. As per medical books: - "Appendectomy is one of the commonest procedures performed in surgical practice. When the appendix is perforated or gangrenous with peri -appendicitis, the frequency of septic complications reaches as much as 30% which includes wound infection, intra -abdominal abscess, fistula formation, and localized or diffused peritonitis. Most of the appendicocutaneous fistula are low output fistulas and close spontaneously within 3 weeks."

AS per literature titled "Faecal Fistula Following Appendicectomy": A Case Report From Journal of Clinical and Diagnostic Research 2012 September (Suppl), Vol -6(7): 1322 -1323; "The Post -appendectomy faecal fistula formation, though it is a rare complication, is associated with significant morbidity. An early diagnosis is essential to institute proper treatment at an early stage of the disease. Most of the fecal fistulae respond to the conservative treatment in the absence of an underlying pathology and distal obstruction. The surgical management should be reserved for those who fail to respond to the conservative management."

We would like to put reliance upon several judgments of Hon''ble Supreme Court on medical negligence.

"• In the Jacob Mathews Case : (2005) 6 SCC 1 it is observed as;

A medical practitioner faced with an emergency ordinarily tries his best to redeem the patient out of his suffering. He does not gain anything by acting with negligence or by omitting to do an act. Obviously, therefore, it will be for the complainant to clearly make out a case of negligence before a medical practitioner is charged with or proceeded against criminally. A surgeon with shaky hands under fear of legal action cannot perform a successful operation and a quivering physician cannot administer the end -dose of medicine to his patient.

• In Martin F. D''Souza v. Mohd. Ishfaq : AIR 2009 SC 2049 case Hon''ble Apex Court observed as;

''medical practitioner is not liable to be held negligent simply because things went wrong from is chance or misadventure or through an error of judgment in choosing one reasonable course of treatment in preference to another - he would be liable only where his conduct fell below that of the standards of a reasonably competent practitioner in his field.''

• In Roe and Woolley v. The Ministry of Health, by Lord Denning, that, We would be doing a disservice to the community at large if we were to impose liability on hospitals and doctors for everything that happens to go wrong.

• Courts/Consumer Fora should keep the above factors in mind when deciding cases related to medical negligence, and not take a view which would be in fact a disservice to the public. The decision of Hon''ble Supreme Court in Indian Medical Association v. V.P. Shantha ( : AIR 1996 SC 550) should not be understood to mean that doctors should be harassed merely because their treatment was unsuccessful or caused some mishap which was not necessarily due to negligence."

IN this case, there appears to be a strained relationship between the Doctor -Patient. The deceased and OP doctor were classmates and close friends. The OP took utmost care and operated upon him as an emergency. The fecal fistula developed due to patient''s health condition. The patient was highly diabetic with high blood urea and creatinine levels. Further, OP took proper care of the fistula by providing regular dressing, antibiotics were given. The death occurred due to multiple factors. We do not find any negligence either during the appendicectomy surgery or during treatment of fecal fistula. Therefore the appeal is hereby dismissed, with no order as to costs.