K MUNIASAMY vs HARLEY RRAM NURSING HOME

-THE present appeal is filed against the order dated 31. 8. 2004 passed by the State Consumer Disputes Redressal Commission, Tamil Nadu at Chennai in Original Petition No. 163/1997 dismissing the complaint alleging medical negligence against the respondent/opposite parties.

BRIEF facts of the case are: the appellants Thiru K. Muniasamy and minor Lavanya are the father and the daughter are 35 years of age and 8 years of age respectively. The first appellant''s-wife is Mrs. Bhanu. Bhanu developed jaundice during her 8 month pregnancy and she went to the opposite party No. 1 (Harley Rram Nursing Home ). She was attended to by the opposite party Nos. 2 to 4, i. e. opposite party No. 2, Dr. R. Venkataswamy, M. S. , CMO, opposite party No. 3, Dr. V. Ramesh, M. S. M. Ch. (Urology), Dy. CMO, opposite party No. 4, Dr. Mrs. Savitri Ramesh, Medical Officer, all working for opposite party No. 1. She was admitted with the complaint of vomiting and fever to the O. P. No. 1 Nursing Home on 8. 4. 1997. Blood sample was sent for analysis and the liver function test was performed on 9. 4. 1997. It indicated that she was affected severely by jaundice. She had serum Bilirubin level at 8. 60 mg. It is alleged by the complainant that opposite party Nos. 1 to 4 failed to treat his wife for jaundice till 15. 4. 1997. Due to their gross negligence, her health deteriorated very rapidly. The admitted facts are : Bhanu delivered a dead male oetus at 2. 15 p. m. on 15. 4. 1997 in O. P. No. 1 hospital. Dr. Thayumanavan, a Consultant in Gastroenterology saw the patient on 14th, 15th and 16th and treatment as advised by him was given. Towards afternoon of 16th, the patient''s condition deteriorated and on the advice of Dr. Thayumanavan, she was shifted to the Jawahar Hospital, Madurai at about 6 p. m. in semi-conscious state. Various specialists like Gastroenterologist, Cardiologist and Nephrologist were consulted and treatment was given.

However, in spite of all these measures, the general condition of the patient gradually deteriorated and at 3. 40 a. m. on 23rd April, the patient died.

THE main allegations of the complainants argued by the learned Counsel are as follows: (i) At the time of admission in the opposite parties hospital on 8. 4. 1997, the opposite parties knew that Mrs. Bhanu was suffering from jaundice but they did not treat her for jaundice. No efforts were made at that time to find out the type of Hepatitis Virus causing jaundice.

(ii) The liver function tests done on 9. 4. 1997 and high levels of Bilirubin and Prothrombin indicate that the foetus was dead on or before 9. 4. 1997 but the opposite parties did not take any steps to remove the dead foetus by a caesarean section immediately.

(iii) The hospital did not have specialists and the opposite parties did not consult the Gastroenterologist till 14th of April, 1997. This delay led to further deterioration in patient''s health.

(iv) They should have transferred the patient to a Tertiary Care Hospital with better facilities to monitor the patient, which they did not do. According to the complainants, these acts of negligence led to the death of Bhanu.

The opposite parties refuted all the above allegations and argued that they took every possible care to control the jaundice and followed well accepted medical procedures. They argued that the unfortunate death occurred due to natural progression of the rapidly spreading disease-Fulminant Hepatic Failure due to Fulminant Viral Hepatitis and not due to any negligence.

THE State Commission went through all these allegations and came to the conclusion that there is no negligence on the part of the opposite parties and hence, dismissed the complainant''s claim for compensation of Rs. 30 lakh. We heard both the parties and went through the records carefully. For the following reasons, we do not find any justification to interfere with the well reasoned judgment and order of the State Commission. Firstly, it would not be correct to say that opposite parties hospital did not have well qualified doctors to attend to the patient, Bhanu. The second opposite party Dr. R. Venkataswamy, is one of the senior most Surgeons in Madurai doing mostly gastroenterology work. Dr. Ramesh, the third opposite party, in addition to doing M. S. has done MCH in Urology. Dr. (Mrs.) Savitri Ramesh has an M. D. degree in Obstetrics and Gynaecology. The hospital of the opposite parties is well equipped. In addition to these doctors on 9th April itself a general Physician Dr. Vijay Rangan, who retired as Professor of Medicine in a Government Medical College, Madurai examined the patient and issued necessary instructions, which were carried out.

SIMILARLY, we find no force in the argument that the patient should have been shifted into a hospital with Tertiary Care. All the three doctors, (O. P. Nos. 2 to 4) are specialists themselves with considerable experience and a good professional reputation. All the necessary tests were got done in time and repeated a week later to know the progress of the disease. Other specialists were consulted whenever the need arose. When her health started deteriorating after the delivery, the patient was immediately shifted on the 16th to a Tertiary Care Centre. In any case, if the complainant felt that no proper treatment was given by the opposite parties, it was open to the complainant to move the patient to the hospital of their choice. The allegation that the specialist in Gastroenterology was consulted only on 14th April does not really help the complainants.

THE disease of jaundice was identified on 8th April itself and treatment started forth with. The opposite party No. 2 Dr. Venkataswamy has 50 years of professional experience, and was honorary Professor of Surgery in the Madurai Medical College. He has stated that mostly he was doing Gastroenterology work. Dr. Vijay Rangan who saw the patient on 9th April, retired as Professor of Medicine. As such, the fact that a Gastroenterologist saw the patient only on 14th, has not materially affected the patient, and cannot be treated as negligence. The only material difference is that the entry of the Gastroenterologist made is, that the Hepatitis was classified as due to ''e'' Virus. But as elaborated in the next paragraph, there is ample evidence on record to show that the treatment to be given is mostly supportive for jaundice, whether it is from Virus ''b'' or Virus ''e'', it is the same. As regards the allegation of negligence that no treatment for jaundice was given, it is seen that on the very day of her admission, the patient was given treatment by administering I. V. Glucose, oral glucose oral B Complex, Vitamin ''c'' and injection Vitamin K. From 9. 4. 1997 to 14. 4. 1997, the patient was clinically doing well. There was no vomiting, her appetite was good, bowels were moving regularly, urine output was good and liver supportive treatment was given daily. A test for Hepatitis ''b'' Virus was carried out on 9. 4. 1997 itself and as the test result was negative, ''b'' Virus was ruled out.

It is true that test for Hepatitis ''e'' Virus was got done on 14. 7. 1997 at Coimbatore because Dr. Thayumanavan, a Consulting Gastroenterologist informed the opposite party No. 2 that Indian Council of Medical Research (ICMR) was conducting the research in Virus Hepatitis at K. G. Medical College, Coimbatore. However, knowing the type of Hepatitis virus was only for assessing the prognosis of the disease, but not to alter the treatment. There is no specific treatment for jaundice and there is only supportive treatment for jaundice which has been given to the patient.

THERE does not seem to be any force in the argument that the foetus must have been dead on or before 9. 4. 1997. The liver function tests are not meant to reveal the condition of the foetus which did not reveal anything about the foetus. Ultrasound scanning was done on 10. 4. 1997 and single live foetus was seen. Foetal heart rate was good and foetal movements were good. Fluid was adequate. Foetal heart was heard by Foetascope and ultra-sonography showed that the foetus was live and movements were there till the delivery of the patient was done. The foetal movement was felt by the patient herself. According to the opposite parties and the case sheet, on examination on 11. 4. 1997 and 12. 4. 1997, the patient was found to be conscious, well oriented and the general condition was good and foetal heart sound was heard by Doppler. Therefore, it would be wrong to say that there was any evidence of intra uterine death and that the opposite parties were aware of that even on 8. 4. 1997. The baby died during the course of premature delivery and it might have been due to Hypoxia during uterine contraction and placental dysfunction. It is contended that if caesarean section was done earlier, she would have died due to, (i) bleeding and (ii) due to anaesthetic complication. The baby died only during the course of delivery and that could be due to pre-maturity, hypoxia during uterine contraction and placental dysfunction caused by the severity of the jaundice. The fact that there was no peeling of the skin and no collapse of the skull of the still born foetus supports the stand of the opposite parties that there was no prior intra-uterine death. Therefore, the question of removing the foetus by caesarean section does not arise.

FURTHER as per the evidence led by Doctors, the deceased was suffering from Hepatitis Virus ''b'', therefore, it was not possible to have caesarean operation for removing the child prior to delivery, otherwise it would have resulted serious consequences for the deceased. According to medical literature, termination of pregnancy is contra-indicated in such cases because of known risk of high mortality for the pregnant woman. The opposite parties filed extracts from a number of text books on Medicine to support their case that acute viral Hepatitis when it strikes pregnant woman in the last trimester, lead to acute or Fulminant Hepatic failure. They relied on the book "obstetrics and Gynaecology for Post Graduate" edited by S. S. Ratnakumar, Bhaskar Rao, S. Anil Kumran, Vol. II "medical Complications during Pregnancy" by Burrow and Duffy, Harrison''s "principles of Internal Medicine", Mudiliar and Menon "clinical Obstetrics" and "diseases of the Liver and Biliary System" by Sherlock. These text books show that jaundice in pregnancy may be caused most commonly either by Hepatitis Virus ''b'' (HVB) or Hepatitis Virus ''e'' (HVE); that the treatment of both is the same; that in fact there is no specific treatment for Hepatitis except rest, diet and supportive treatment; that Hepatitis ''e'' Virus could cause Fulminant Hepatic Failure (FHF), especially in the third trimester; that there is no place for termination of pregnancy in Viral Hepatitis; and that HEV in pregnant woman, specially the third trimester is associated with premature delivery and also with high mortality, approximately 10-35% of instances.

FURTHER, when acute/viral hepatitis (of any type) strikes a pregnant woman in the last trimester, a rare but well-known complication is Acute (or Fulminant) Hepatic failure, marked by considerable risk of maternal and perinatal death. "acute (or Fulminant) Hepatic failure" (AHF or FHF) is defined as a rare syndrome in which Hepatic Encyclopathy characterized by mental changes progressing from confusion to stupor and coma, result from a sudden severe impairment of Hepatic function. The syndrome is defined further as occurring within eight weeks of onset of the precipitating illness, in the absence of evidence of pre-existing liver disease to distinguish it from those instances in which Hepatic Encyclopathy represents a deterioration in chronic liver disease.

IN this case, Dr. Thayumanavan who saw the patient on 14th April diagnosed the disease as "acute Viral Hepatitis complicating pregnancy with increased prothrombin time". The cause of death has been shown as "fulminant Hepatitis Failure" by the Jawahar Hospital. It is thus clear that Bhanu who was admitted in the opposite party hospital "with acute viral Hepatitis" in third trimester of her pregnancy, has unfortunately developed the rare, but known complication of acute Fulminating Hepatic Failure, which caused premature delivery of the foetus, and the ultimate death of the mother. There was nothing that doctors could do to prevent this tragedy in this situation. Further, the complainant has not produced any expert opinion to show that the course of treatment followed was ill advised. It is not established that there is any irregularity with the treatment and that there is lack of reasonable care in treating the patient. The doctor is expected to render service with reasonable care in the given circumstances and one connot expect the doctor to guarantee the results. Just because an unfortunate death occurred, no presumption of negligence would result therefrom. There is absolutely no material to show that the death was caused for want of proper care and attention by the opposite parties.

In view of the aforesaid discussion, the appeal fails and is dismissed. There shall be no order as to costs. Appeal dismissed.