D. SRIVALLI vs SHOBHA BALKRISHNA (DR.)

THIS original complaint is filed by Miss, D. Srivalli against the opposite parties alleging medical negligence. She was 28 years old at the time of filing of this complaint. Her case is that over a period of 4 months, i.e., from April 1995 to August 1995, she was having continuous pain in the right side of the abdomen. The Central Government Health Scheme Hospital at Kanchanbagh which examined her during this period referred her to O.P. No. 1, Dr. Shobha Balkrishnan, a Specialist in General Surgery and Consultant at the Gagan Mahal Nursing Home, O.P. No. 2. The complainant approached Dr. Shobha on 19th August, 1995. The complainant was told that she is having Appendicitis and that she needs surgery for the removal of the same. On 23rd August, 1995 when the complainant consulted the O.P. No. 1 the latter gave a list of test to be undertaken before the surgery. On 24th August, 1995 the complainant was admitted in the hospital and on the same day an ultrasound of the abdomen and the pelvis was done at the Gagan Mahal Nursing Home by Dr. Jyothi Roy.

IT is alleged that the results of the ultrasound tests were not made known to the complainant at that time. She was taken in for surgery at 9.30 a.m. on the next day, i.e., on 25th August, 1995. The complainant alleges that in addition to removal of the appendicitis, her right ovary and part of the fallopian tube were also removed by the Surgeon, O.P. No. 1 and O.P. No. 3. Subsequent to the operation, she was told that her right ovary had a big cyst and that it is affected by Endometriosis and that part of the fallopian tube was said to be bent and adhered to the ovary and since it could create problems in future, part of the fallopian tube was also removed. The complainant alleges that his removal of the right ovary and the fallopian tube was unwarranted. It is a case that if there was a cyst, the liquid in the cyst should have been drained or utmost the cyst should have been removed and that there was no case for removal of the ovary. As far as fallopian tube is concerned, it is argued that there is no disease in the tube and that there was no reason to remove it. It is alleged that this removal was done without the consent of the complainant and that the removal of the right ovary and part of the fallopian tube has jeopardised chances of her marriage and reduced her chances of becoming pregnant by more than 50% and further it has caused her mental agony, and the complainant claimed a compensation of Rs. 40 lakh.

The case of the opposite parties is that when the complainant came to them on 19th August, 1995, she was suffering not only from appendicitis but also from an enlarged right ovary. However, on 19th August, 1995, she presented herself for the first time before O.P. No. 1, she did not bring all the papers relating to her previous case history. She approached O.P. No. 1 again on 23rd August, 1995 with the relevant case history papers, it was noticed that she was having an enlarged right ovary. A fresh ultrasound of the abdomen and the pelvis was got done on 24th August, 1995 which showed that the right ovary had considerably expanded over the previous two months and that there was a large cyst. Therefore, on the night of August 24th itself, the complainant was told about the presence of the big cyst in the right ovary. She was also told that the ultrasound scan does not give the entire accurate picture of the damaged inside and that since the abdomen in any case has to be opened for the removal of the appendicitis, the actual status and condition of the cyst in the right ovary would be revealed at the time of surgery and that if the situation so demands, surgery may have to be done for the removal of the cyst also simultaneously. It is the case of the opposite parties that O.P. No. 3 who is Gynaecologist has been called on the morning of August 25, 1995 to examine the patient and her medical reports before the operation.

IT is also argued by the opposite parties that after opening of the abdomen, a large cystic mass on the right side of the pelvis with dark coloured fluid embedded in the pouch of Douglas with adhesions to the surrounding organs was found. The right ovary completely enlarged and the whole ovary was replaced by a large cystic mass. No normal ovarian tissue could be seen separately. Endometriosis is present at the cyst. Endometriosis is the disease that easily spread to surrounding organs and hence removal of this disease from ovary became mandatory. The right fallopian tube was also stretched out distorted and adhered to cystic mass. Such an enlarged distorted adhered tube will have defective mobility (i.e., propogation of fertilized ovum towards the uterine cavity, the usual site for implantation which is the most important function of the fallopian tube. A defect in the mobility of the tube prediscopes ectopic (or tube) pregnancy which could be a dangerous condition, and hence distorted tube was required to be removed. It is their further case that the subsequent histopathological report of the removed ovarian cyst clearly shows that the ovary had endometriotc cyst and that the fallopian tube was densely adhered to the ovarian cyst. Though histopathologically the fallopian tube did not itself show any disease, adhered tube as stated above, cannot perform its normal functions and chances of subsequent ectopic pregnancy are greatly enhanced in such cases.

IT is argued that the removal of the disease ovary does not compromise future fertility and that the complaint is misplaced and needs to be dismissed. We have gone through the record carefully and heard the arguments of the parties. The case is quite simple and straightforward. It is an admitted fact that during the period from 13.4.1995 to 19.8.1995, the complainant was taking treatment for continuous pain in the right side of the abdomen at the CGHS Hospital, Kanchanbagh. On 19.8.1995, the complainant was referred to Dr. Shobha Balkrishnan, O.P. No. 1 for expert advice. Dr. Shobha has stated on affidavit that on 19.8.1995 the previous reports were not brought by the patient. However, the notings dated 23.8.1995 of O.P. No. 1 show that the previous reports were produced. The previous reports contained two ultrasound screening reports. The first one (Exhibits C-5) dated 22.5.1995 done by one Dr. P.K. Shrivastava of CGHS indicates clearly that the right ovary was enlarged with multiple follicles. The size of the right ovary is shown as 4.2 x 4.2 x 4.7 c.m. The ultrasound report (Exhibit C-5A) dated 12.6.1995 by the same Dr. P.K. Shrivastava gives dimensions of the right ovary 4.4. x 3.1 x 4.5 cm. with multiple follicles. This is certainly an enlarged ovary because it has come on record that the normal size of ovary is 2.5 x 2x3 cm. Because of this, O.P. No. 1 ordered a third ultrasound screening which was done on 24th August, 1995 in her own hospital. This report done by Sonologist Doctor Jyoti Roy shows that the right ovary is considerably enlarged in size, the size being 7.6 x 6.7 cm. This clearly shows that the right ovary had doubled in size in two months time. In addition, Exhibit C-3 (the third Sonography report) shows that there are multiple cysts with the large cyst measuring as much as 3.5 c.m. x 4.2 c.m. Once the third sonography report is available, we do not see any reason as to why O.P. No. 1 would not share the information with the complainant. We do not, therefore, believe the version of the complainant that the report was not shown to her. O.P. No. 3 has clearly stated in her deposition that the report was very much available at the Nurses Station and there is no reason to disbelieve it. In the light of not one but these three reports, we have to accept the version of O.P. No. 1 that the complainant has been told on 24th August itself that there is a possibility of removal of the cyst depending on its condition after opening the abdomen. If it was not planned to examine the cyst and if necessary to remove it, there is no reason to call another specialist, namely the Gynaecologist (O.P. No. 3) just prior to the surgery to examine the patient and the ultrasound report.

THEREFORE, we rely on the statement of O.P. No. 3 that during the operation, the mother of the complainant was informed that the right ovary has to be removed under the circumstances which revealed themselves after opening of the stomach. The complainant who is well educated and an advocate by profession has given her consent on 24th August, 1995 by signing the form. The consent form inter alia, has an undertaking "I also give my consent for any change in the operative line of treatment or any other operation deemed fit in the best interest of my health."

AT the instance of complainant, a number of witnesses have been examined through a Commissioner appointed by this Commission. However, there is nothing in their deposition, which is relevant to the issue under consideration. Similarly, a number of references have been made to medical text books by both sides to show that a decision whether ovary should or should not be removed when it has a large cyst. We do not think that it is necessary to refer to all these references. Almost all references state that whether the ovary with multiple cysts and with endometriosis should be removed or not depend on each individual''s case. However, it should be enough to make reference to the "Text Book of Gynecology, Jeffcot" by Lipschitz Law at P53 which clearly states that the removal of the diseased ovary does not compromise future fertility. From the evidence on record, it is clear that the complainant has been under treatment for continuous pain in the right side of the abdomen for a period of over four months prior to the operation. In all, three ultrasound screening tests were done on her and all of them showed a rapidly growing right ovary with multiple cysts with one of them occupying more than half of the right ovary. She was thus fully aware of the disease of the right ovary. She was advised the night before the operation that at the time of the operation, a gynaecologist would also be present to examine her condition of the affected ovary and the ovary would have been removed, if necessary.

After opening the abdomen it was clearly seen that the right ovary was diseased and that the cyst and ovary could not be separated and that the fallopian tube was twisted and could cause health problems in future. The complainant herself had given a written consent that any other operation can be performed on her in the best interest of her health. In this case, the operating surgeon felt that in the interest of the complainant, the diseased ovary and part of the fallopian tube had to be removed. Subsequent to the operation, the histopathology report confirms the disease in the removed organ. This clearly shows that there has been no neglect on the part of the surgeon at any stage of the operative procedure. As a matter of fact, they had taken whatever best steps are necessary in the best interest of the health of the complainant. In view of this, we do not see any substance in this complaint and it is dismissed accordingly. Complaint dismissed.