FAKRUDDIN ABBAS BHARMAL vs B. DASGUPTA

THIS complaint is filed by the son Fakruddin Abbas Bharmal on behalf of his father Abbasbhai Yusufalli aged about 50 years for award of compensation of Rs. 5,16,601/- against the opposite party No. 1-Dr. Dasgupta, opposite party No. 2-Medical Officer of Mumbadevi Hospital, Mumbai and opposite party No. 3-D.S. Kothari Hospital, Mumbai, in respect of negligence committed by the opposite parties in the operation and treatment for HERNIA, which took place on 1.2.1994. Abbasbhai, however, died on 3.3.1994 in his last lap of J.J. Hospital. He was admitted in the J.J. Hospital only a day before hisdeath. The complainant has contended that the Mumbadevi Hospital on 31.1.1994 admitted the patient for Hernia operation and the operation was performed on 1.2.1994 by opposite party No. 1-Dr. Dasgupta. However, the patient started bleeding through the anus and as there was no Intensive Care Unit in the said hospital, he was transferred to opposite party No. 3-D. S. Kothari Hospital on 4.2.1994. He was treated at Kothari Hospital by Dr. H.M. Shah. The complainant has contended that although the operation went of uneventful and although such an operation did not visualise even remotely the death of the patient, the patient succumbed to death on account of the negligent treatment by the opposite parties. According to Dr. Shah, of opposite party No. 3 the patient suffered from septicaemia and renal problems because of the negligence in the treatment at Mumbadevi Hospital. Dr. Shah tried to discuss the deteriorating condition of the patient with opposite party Nos. 1 and 2. They did not co- operate and thus, the patient died on account of negligence of the opposite parties. The post- mortem notes revealed that the death was on account of septicaemia with acute renal failure.

THE deceased was doing the business under the name and style of ''Apco Steel Tube'' at Bombay and was earning around Rs. 3,000/- per month. He left behind son, widow and daughter and that looking to the future span of life, the claim of Rs. 5,16,601/- is fully warranted. THE heads of the claim includes expenses at the hospital, loss of consortium, expectation of life, expenses on attendants, special diet and loss of contribution by the deceased to the family at the rate of Rs. 1,500/- per month for a period of 20 years. Opposite party No. 1-Dr. Dasgupta contended thathe isa qualified Surgeon and that the patient was operated by him on 1.2.1994 for Hernia in the Mumbadevi Hospital. The patient was transferred in a stable condition on time as he was going in for impending renal shutdown, which required I.C.U. and dyalisis. As Mumbadevi Hospital did not have that facility, the patient was transferred to Kothari Hospital on 4.2.1994 at 4.30 p.m. At the time of transfer, there was absolutely no infection of left inguinal wound. His blood pressure was 100/70mm. mg. and pulse 110 mt. He was fully conscious and was co-operative and this is borne out by the hospital papers. Opposite party No. 1 denied that the patient started bleeding while he was in Mumbadevi Hospital. There were only loose motions, one vomit and no blood in either. He was discharged on 4.2.1994 and that the Discharge Certificate gives in details the condition of the patient and the management of the patient at Mumbadevi Hospital. It is not true that the patient was suffering from septicaemia when he was admitted to Kothari Hospital. Dr. Shah''s certificate dated 24.11.1994 is clearly an afterthought to get out of the responsibility for the treatment given in Kothari Hospital from 4.2.1994 till 2.3.1994. The patient was transferred to J.J. Hospital on 2.3.1994 and he died on the next date. The certificate dated 24.11.1994 would show that the septicaemia was not present at the time of admission of the patient at Kothari Hospital and that the same is not true. It is further denied that there was any discussion between the doctors of Mumbadevi Hospital and Kothari Hospital and that Mumbadevi Hospital doctors refused to co-operate. The patient developed septicaemia and renal failure because of the negligence at Kothari Hospital and not at Mumbadevi Hospital and there was, therefore, no question of awarding any compensation against the Mumbadevi Hospital. In this light of the contentions, the claim of the complainant is denied. Mumbadevi Hospital has adopted the defence of opposite party No. 1-Dr. Dasgupta.

D.S. Kothari Hospital has filed their written statement wherein the allegations against Kothari Hospital are denied. According to that hospital, the patient was operated for left Inguinal Hernia on 1.2.1994 and that he was shifted to Kothari Hospital on 4.2.1994. At the time of admission of the patient at Kothari Hospital, the condition of the patient was poor and that the said patient had post-operatively developed loose stool 5-6 times a day, bleeding per rectum, vomiting and severe itching all over the body followed by hypotension and oliguria with hypotensive shock. According to J.J. Hospital post-mortem notes, the cause of death was ''Septicaemia with Renal Failure''. The patient was treated properly at the Kothari Hospital and the patient was however found to be Tachypnic- 44 per min. RR., Pulse 150 per min./ regular blood pressure-110/80. Mild Cynosis, Chest-clear, per abdomin distension ++, Bowel sound-poor, AG- 88 cm., CVS-S1 S2 +, CNS -Conscious Oriented. The operated site was found to be swollen. There was redness, tenderness, inflammation, induration and pus discharge. The provisional diagnosis of the said patient was post-operative septicaemia with acute renal failure and his blood urea was 119 and Serum Creatine-3.4 mg%. The patient, thereafter, started passing stools which showed coffee coloured aspiration. The patient was then referred to Nephrologist- Dr. Hemant Mehta and a General Surgeon-Dr. S.P. Deshmukh for his wound. On 5.2.1994, the urine output of the said patient increased and few stitches and pus drained out from the site of operation by Dr. Deshmukh. However, the patient was still Tachynic and Tachycardia ++ accompanied by passage of black coloured stool and coffee coloured aspiration of R/T persisted. The daily dressing of the wound continued. On 7.2.1994 also the patient was Tachynic, Tachycardia ++ and his remaining sutures were removed and would opened up completely and dressing was done. This was followed by appropriate treatment. On 12.2.1994, the said patient was haemodynamically stable and hence was shifted to the ward. The Ryle''s tube showed coffee coloured aspiration and the patient was passing black coloured stool. On 13.2.1994, in view of his high WBC count and hypokalemia he was shifted back to ICCU. The patient had Malena ++and was disoriented. It was observed that due to internal bleeding the patient was Tachypnic ++ and Tachycardia ++. On 16.2.1994, Dr. Deshmukh performed desloughing of wound and dead tissues were removed. The patient was also referred to Dr. Ashok Shah-Endoscopist for the patient''s Malena. Between 17.2.1994 to 23.2.1994 the patient was appropriately treated, but his Malena persisted. His Haemoglobin was decreased and his WBC count increased. Dr. Hemant Mehta-Nephrologist managed the patient. On 23.2.1994, the patient was again shifted to ICCU. His condition was poor, Tachypnic, Tachcardia, and his Malena persisted. This was inspite of appropriate antibiotics and blood transfusion. On 2.3.1994, the patient requested for his discharge because he could not afford heavy expenses of the hospital. He was, therefore, sent to J.J. Hospital. Kothari Hospital has thus briefly submitted that the patient was treated all along properly and that the hospital is not responsible for the compensation. All other averments in support of the claim are stoutly denied by the said hospital.

OPPOSITE party No. 1-Dr. B. Dasgupta has furnished the affidavits of Dr. Harkishen J. Koticha and Dr. Ramesh S. Kamat in order to show that neither Dr. Dasgupta nor Mumbadevi Hospital are responsible for the death of the patient. Dr. Dasgupta has also filed an affidavit in reply to the written statement of the Kothari Hospital. Dr. Sanjay K.N. has filed an affidavit on behalf of the Kothari Hospital inter alia controverting the affidavits of Dr. Koticha and Dr. Kamat. Here we find that the following facts are not in dispute. The patient Abbasbhai was admitted to the Mumbadevi Hospital on 31.1.1994 and that he was operated for left Inguinal Hernia on 1.2.1994 under epidural anesthesia. He was shifted to Kothari Hospital on 4.2.1994 in the noon, because the patient needed ICCU. He was at the Kothari Hospital till 2.3.1994. On request of the patient and his relatives, the patient was removed to J.J. Hospital on 2.3.1994 and that he died on 3.3.1994. The post-mortem notes issued by the J.J. Hospital clearly shows that the death of the patient was on account of septicaemia with acute renal failure. These observations are based on the clinical history, clinical impression, autopsy notes, his to path report, post-mortem notes, post-mortem diagnosis, hospital reports and the impressions by the doctors. We, therefore, conclude that the death was on account of septicaemia with acute renal failure. We may state here that in the affidavits of doctors, more particularly. Dr. Kamat, there is a suggestion that the medical reports do not conclusively establish that patient suffered septicaemia. But we believe that such doubt will have to be dispelled in view of the opinion in the post mortem report. The other symptoms discussed by the doctors are also indicative of Septicaemia coupled with acute renal failure.

WE, therefore, initially traverse through the hospital papers of Mumbadevi Hospital. In the report submitted to Kothari Hospital on 4.2.1994, it is stated that the patient was operated for left Inguinal Hernia on 1.2.1994. Left Inguinal Herniorrhaphy was done with Epidural Anesthesia by Dr. Dasgupta. On the third day the patient had loose motions 5-6 times coupled with vomiting once with severe itching all over the body and wheels all over the body, followed by patient developing hypotension and oliguria and that he was not responding to I.V. fluid therapy. Hypotension was found to be persistent and fluctuant. Physician''s reference was given and Physician suggested transfer to ICU for hypotensive shock with CVP monitoring. The said letter is also annexed to the investigation report. At the time, when the patient was forwarded i.e. on 4.2.1994, the patient had no vomiting and no loose motions. CVS of course showed Tachycardia. Now these are the symptoms, when Abbasbhai was transferred to Kothari Hospital. Dr. Dasgupta has attached case papers of Mumbadevi Hospital, which clearly shows that on 3.2.1994 at 4.30 p.m. loose motions were noticed but there was no blood. However there was itching all over the body and hence the necessary treatment was given possibly antibiotic tablet, which is for treatment of itching. At 7.15 a.m. with the treatment, itching went down. There was loose motion only once. Tongue was found to be dry coupled with dehydration but then it seems that intravenous fluids were given at a fast rate. At 8.30 p.m. the patient had practically gained on all fronts namely afebrile. No vomiting, no loose motions but there was itching all over the body coupled with wheels. At 9.00 p.m. of course, itching had disappeared. On the next day i.e. 4.2.1994 everything seems to have gone alright. When he was forwarded to Kothari Hospital, we find that the patient was normal on all fronts. However, there was tachycardia i.e. increase in blood rate. Now, in all these notes we do not find the wound getting red and that there was swelling and blood was traced in the stools or even in the urine and according to Dr. Dasgupta, the patient really did not have septicaemia when he was transferred to Kothari Hospital. In the Harrison''s Book of "Principles of Internal Medicine", page 776, it is stated that, fever or hypothermia, tachypnea and tachycardia often herald the onset of sepsis, the systemic inflammatory response to microbial invasion. Septiceamia means systematic illness caused by the spread of microbes or their toxins via the bloodstream. The symptoms are that some patients have a normal temperature or are hypothermic; the absence of fever is most common among neonates, elderly patients and persons with uremia or alcoholism. Successful management requires urgent measures to treat local infection, to provide hemodynamic and respiratory support and to eliminate the offending micro organism. Antimicrobial chemotherapy should be initiated as soon as samples of blood and other relevant sites have been cultured and thereafter, the specific therapy should be followed. The treatment can be simplified as soon as microbial agent is detected. Now this would mean that when the septicaemia is discovered or is about to start on the basis of symptoms, the blood culture and other side cultures should be done so as to adopt a specific aggressive anti-microbial chemotherapy. Blood cultures yield bacteria or fungi in approximately 20 to 40 per cent of cases of severe sepsis and 40 to 70 per cent of cases of septic shock. Now we have indicated that when the patient was in Mumbadevi Hospital there were symptoms which did not indicate the existence or commencement of septicaemia. The patient was almost normal because he did not have blood in the stools nor exhibited any symptoms except tachycardia which may not be conclusive of existence of septicaemia.

IN this regard, opposite party No. 3 has relied on the certificate dated 24.11.1994, a date much later than the death of Abbasbhai. It is sought to be suggested that the patient was transferred from Mumbadevi Hospital had already septicaemia, but that is not borne out from the contents of the certificate. It only shows that on the 3rd post-operative day the patient was admitted to Kothari Hospital and was diagnosed as a case of post-operative septicaemia with acute renal failure. His pus discharging wound was debrided under local anesthesia by the Surgeon on 16.2.1994. It has been argued on behalf of the Advocate for the complainant and Advocate for opposite party Nos. 1 and 2 that if the septicaemia was detected at the time of admission, debridment on 16.2.1994 was extremely late. It is also pointed out that upto 5.2.1994 and thereafter on 7.2.1994, there was no specific treatment in respect of septicaemia to which we may come later.

THE certificate dated 24.11.1994 does notnecessarily show that the patient had suffered septicaemia at Mumbadevi Hospital. THE case papers do not indicate in that behalf. Even the case papers of Kothari Hospital are not indicative of the existence of septicaemia at the time of admission. It only shows that the patient developed loose motions, hypotension and oliguria which may be symptom relating to commencement Kidney operation. However, there is a clear observation that from the wound site pus was coming out. THEre was swelling, tenderness, etc. Now in this regard, we may turn to the affidavits of Dr. Dasgupta, Dr. Kama t and Dr. Koticha. Dr. Koticha is a Consultant Surgeon attached to Dr. Balabhai Nanavati Hospital and he has stated that the operation was uneventful, but on 3.2.1994, the patient developed skin rashes all over the body. THEre were 5-6 loose stools but no blood was detected. He was, therefore, treated with simple anti-allergenic drugs, intravenous fluids, etc. His blood pressure was low and there was fall in the systolic blood pressure. On 4.2.1994, Dr. Khanna of Mumbadevi Hospital advised transfer to an Intensive Care Unit and accordingly, he was admitted to Kothari Hospital, where the facility was available. He was looked after by Dr. Shah-Physician. THE wound was found to be swollen, red, painful and was discharging pus. On 8.2.1994 the temperature touched 100 F, but three days thereafter the patient was a febrile. THE debridement and would toilet was done on 16.2.1994 and Dr. Koticha has questioned that during this period the patient was not attended to in regard to pus to discharge or slough. THE pus or discharge or slough should have been subjected to bacteriological examination namely, smear, culture, antibiotic sensitivity testing. On the diagnosis of post- operative septicaemia (which means fulminant infection with bacteria invading blood), there was no blood culture report. Pus examination and blood culture are the routine in a given situation. THE subsequent record shows that there have been increase in blood urea and creatinine levels, denoting progressive impairment of renal functions. THE patient pulled out the Central Venous Pressure Line introduced only the previous day and with special consent it was reintroduced on the next day. THEre was every likelihood of the CVP line catheter being invested and aggravating septicaemia. THE Haemoglobin levels had also fallen and the blood colour stools meaning loosing blood from the gastrointestinal tract. First blood transfusion was done on 15.2.1994 and thereafter till thcday of transfer to J.J. Hospital. Multiple blood transfusion can contribute to septicaemia. Now, with this affidavit on record, we can say that the Kothari Hospital ignored obtaining blood culture report, pus discharge or stool examination report which will have facilitated the treatment in a specific direction. Such a fundamental measure has not been taken by the Kothari Hospital. THE diagnosis of septicaemia would have been confirmed by blood culture. Dr. Kamat also in his affidavit has stated that although the surgical wound found to be discharging pus on 4.2.1994, bacteriological investigations namely smear, culture and antibiotic sensitivity testing and the alleged persistent discharge was not done. Further despite the clinical diagnosis of septicaemia blood culture was not done. This has not been found in the hospital papers of Kothari Hospital. The procedures of frequent blood transmission, insertion of Central Venous Pressure Line may give rise to risk of infection.

Dr. Dasgupta in his affidavit in rejoinder has stated that in the certificate of Kothari Hospital, there is a reference that there was septicaemia which is not borne out. On the other hand, even though the pus was discharged from the operation site, no steps have been taken for debridment upto 16.2.1994 by Dr. Deshmukh of Kothari Hospital. The internal bleeding might be on account of intestinal ulcer.

DR. Sanjay K.N. has stated that there may not be fever in elderly patients and that the existence of fever till 8.2.1994 could not mean that the patient was not in septicaemia. It is also stated that no blood culture was necessary because thepatientwasalready on antimicrobial therapy. Even the microbial therapy in the absence of blood culture may contribute to septicaemia. It is stated in the above book, that anti microbial agents must be chosen empirically and must be active against the range of potential infectious agents consistent with the clinical scenario. In contrast, good clinical judgment sometimes dictates withholding of anti- microbials in a self-limited process or until a specific diagnosis is made and it should be remembered that all anti-microbials carry a risk to the patient. Hence, the treatment of specific microbial agent based on the basis of blood culture should be adopted. The statement of DR. Sanjay in this regard cannot be off accepted against what is stated as above. We, therefore, feel that the patient was in the hospital for about 28 days, that the hospital did not carry out the necessary treatment in regard to blood culture and other bacteriological tests, which could have determined a specific course of action of treatment. There was no early attention to the pus oozing in jury and with such a state of affairs, there is every likelihood tha t Abbasbhai suffered septiceamia with acute renal failure. It cannot be doubted that septicaemia if treated early, is reversible, but unfortunately, Kothari Hospital did not pay the necessary attention to the treatment as suggested above. The above discussion clearly shows that the Kothari Hospital has failed to render service in the treatment of Abbasbhai.

ABBASBHAI was aged about 50 years and was in active business. The Kothari Hospital must bear the expenses on medicines, treatment, etc. of Rs. 62,601/- for which vouchers are on record. The complainant and the widow of the deceased are entitled to pain, suffering and loss of consortium and loss of expectation of life which has been quantified at Rs. 35,000/-. Higher claim was maintainable, but since the claim is confined to Rs. 35,000/-, the same is granted. The complainant has claimed Rs. 2,000/- for attendant, Rs. 5,000/- for special diet, which we feel should be awarded to the complainant. The loss of contribution of Rs. 1,500/- per month for 15 years is permissible because ABBASBHAI had crossed 50 years of his age. ABBASBHAI would have participated business for next 15 years. This amount comes to Rs. 2,70,000/-. The complainant is entitled to cost of Rs. 10,000/-. Rounding the amount the complainant is entitled to Rs. 3,84,000/- from opposite party No. 3-D.S. Kothari Hospital. This amount shall carry interest @ 15% p.a. from the date of complaint till actual payment. Accordingly, we pass the following order : ORDER "The complainant is entitled to Rs. 3,84,000/- with 15% interest thereon from the date of complaint till actual payment from opposite party No. 3-D.S. Kothari Hospital. The claim against opposite party Nos. 1 & 2 is dismissed." Complaint allowed with costs.