KAMLA PATNI vs APOLLO NURSING HOME

THIS appeal is directed against the following operative part of the order dated 30th December, 2002 passed by the Madhya Pradesh Disputes Redressal Commission dismissing O.P. No. 19/1996: "From the hospital record and evidence submitted by the opposite parties, we find that the patient Nirmal Kumar Patni had previous history of CVA with Right Hemiparesis for last ten years. The Patient had old disease of Right side Spastic Hemiparesis and large Non-haemorrhagic infarct and the patient was admitted with history of vertigo and subjective heaviness to right upper limb and right lower limb and on careful examination by the neurological specialist Dr. Sunil Athale it was found that the patient had right side Spastic Hemiparesis and positional vertigo and mild postural hypotension. Drop of 20 mm/hg in systolic BP in five minutes was also observed by Dr. Sunil Athale and were recorded on the papers of the hospital. It was found that the patient had no neuro-deficiency and it was concluded the patient had positional vertigo and posterior circulation inschaemia. The blood sugar of the patient was under control and for this medicine Stugeron was added because sugar level was under reasonable control, therefore, there was no necessity of giving insulin. We are of the opinion that there is no negligence or carelessness of the opposite party Doctors while treating the patient though it was unfortunate that even after all best treatment and efforts patient has died due to Cardiac Respiratory Arrest. To conclude, we find that there has been no negligence in diagnosis, investigation, examination, treatment and management of the deceased patient Nirmal Kumar Patni by the opposite party Nos. 1 to 5 doctors. In the result, the complaint is devoid of merit and is dismissed with no order as to costs".

Case of the appellant is:

LATE Shri Nirmal Kumar Patni, who was the husband of the appellant No. 1 and the father of appellant Nos. 2 to 4 was a patient of diabetes and hypertension, and was treated by Dr. Shashank Vaidya for quite some time prior to 25.7.1995. On 25.7.1995, Shri Patni was advised to be admitted in the Apollo Nursing Home, Indore by Dr. Vaidya and upon the advice of the doctor, the complainants immediately got him admitted in the Apollo Nursing Home. After the admission of the patient, Shri Patni, in the Nursing Home, Dr. Vaidya, Dr. Rajesh Kasliwal and Dr. Santosh Padhye were treating him continuously from 25.7.1995 till 29.7.1995, the date when the patient expired. Athale was also called on 27.7.1995 by Dr. Kasliwal and Dr. S.A. Vadiya. He died at the age of 62 years. The case of the appellant is that during his stay at Apollo Nursing Home, the opposite parties treated the patient with utter negligence and carelessness which caused his death.

Mr. S.K. Sharma, learned Counsel for the appellant argued that late Shri Patni was an old patient of diabetes and B.P. and he was admitted to the Apollo Nursing Home on 25.7.1995. He suffered from giddiness, vertigo and heaviness on the right side of the body. The provisional diagnosis indicated that there was haemorrhage inside the brain. He quoted certain extracts from Dr. Heeresh Chandra''s Medico Legal consultancy report dated 2nd August, 1997: "The C.T. Scan was not done as the machine of the Nursing Home was out of order and, as such, immediate investigations which were of the prime importance were not conducted. In the absence of the above investigation, correct diagnosis could not be made and treatment provided. The patient was an established case of diabets and it was well known to the doctors. Fructose 10%, I.V. was given to the deceased patient without monitoring the urine for ketoasidosis. Insulin was not added to the drip. Echocardiography for detecting the source of thrombosis and evaluation of ischemic heart was not done. The doctors arrived at a conclusion that, there is a brain stem infarct. But the belated C.T. Scan done on 29.7.1995 did not suggest and support the above diagnosis nor there were symptoms of the same. The diseased become gradually comatosed due to ketoasidosis or cerebral failure or ischemic heart disease or the combination of all of them, resulting in peripheral vascular failure. It is alleged in the complaint that there was overall negligence in the dianosis, investigation, treatment and management which ultimately resulted in the death of the patient late Shri Patni". According to Dr. Heeresh Chandra''s opinion : (1) "Probably, it is a routine not to sign the finding of the examination and the prescription given by the examining doctor of such a serious patient but for few places, particularly on 29.7.1995, when the patient was examined and very serious. Only signature available is for the period 17.00 hrs. to 17.30 hrs. which are illegible." (2) "When fasting blood sugar was 266 mg. on 29.7.1995 and acetone was small, prescription indicates that fructose 5% was ordered 1 pint to be given slowly. Nothing to nutralise the sugar was given and to combat respiratory depression. Even the oxygen was not prescribed. The oxygen inhalation was only ordered at 17.00 hrs. at 29.7.1995." (3) "It was ordered that, heparin should be given after C.T. Scan on 29.7.1995 at 9.30 hrs. Injection heparin (5000 units) q.i.d. was ordered at 17.15 hrs. but this timing has been scratched on the order sheet. (4) In the presence of such a high level of urine sugar, acetone present, the distended bladder, why decadron i.v. was introducted is also a point of consideration. (5) On 29.7.1995 at 11.00 hrs. patient was seen by Dr. Vaidya and it was not considered to shift the patient to ICCU when there were indications of crisis arising".

IN his analysis he has given the following details: On 28.7.1995, fasting blood sugar was 180 mg. and the patient complained of "Chakkar" on sitting, it means that the blood sugar was not being regulated by the oral anti-diabetic tablet. It is an established practice that in chronic patients with other acute conditions, oral tablet should not be relied upon and insulin must be given. It is difficult to understand that why insulin was not considered by any of the physicians.

THE anticipated damaging result became apparent on 29.7.1995 when fasting blood sugar rose to 266 mg. with distended bladder. A small amount of acetone was also present. Mr. Sharma, learned Counsel submitted that though the respondent had an opportunity to cross-examine this Doctor, they had not done so earlier. Dr. Heeresh Chandra according to him was a highly qualified doctor and held very eminent positions. He was not cross-examined on any point. He further argued that in this hospital there was a Diabetalogist and a Neurologist but still they did not take full care of the patient. Though the fasting blood sugar was 180 mg. and the patient was complaining of giddiness, insulin was not administered by any one of the Physicians. On the other hand, fructose was given from time-to-time which has resulted in increase in blood sugar level. Apart from not giving insulin, oxygen was also not given to the patient at the appropriate time. He submitted that the essential tablet was administered only on the date of death as can be seen from the reply to the complaint by O.P. Nos. 1, 2, 3 and 4: C.T. Scan did not reveal any fresh changes in comparison to old scans taken 1 years and 3 years back. Within 4 hrs. of the scan, the patient had diffculty in swallowing. Dr. Athale and Dr. Vaidya were informed of this fresh development and also of the C.T. Scan findings, Dr. Athale was of the opinion that symptoms and signs point towards Brain stem infarction and many a time C.T. Scan may not show infarcts at such places and he advised to start Heparin. The expert opinion clearly contradicts the statements made by Dr. Athale. Case of the respondent:

LEARNED Counsel for the respondent, Mr. Ajay Mishra submitted that Dr. Chandra may have several qualifications but he does not possess qualifications in medicine and surgery. He quoted some local newspaper reports which were critical of the professional role of Dr. Chandra. As the appellant had filed a case before the Supreme Court and the respondents were busy in preparing for that case which ultimately was dismissed as the complainant''s Advocate was absent all the time and as Dr. Chandra died before hearing of the matter, there was no occasion to cross-examine Dr. Chandra. Apollo Nursing Home has very good infrastructure. The patient was a known case of non-insulin dependent diabetic. The Counsel claimed to be a diabetic patient himself. He gave a detailed medical analysis of insulin dependent diabetes and non-insulin dependent diabetes.

SHRI Mishra stated that at all stages, the patient was seen by the experts in the hospital and he was given the right treatment as can be seen from sister''s daily records which has been submitted. As the patient was non-insulin dependent, he was not administered insulin as it could aggravate the problem. He further argued that Dr. Chandra has given the judgment and not the opinion. In the legal notice they have stated that their clients have an impression that the fact of holding of the provisional diagnosis has been manipulated in the records. Further in the complaint they have stated that all the opposite parties are in collusion with each other forged medical records of the deceased and supplied photocopy of the same to the complainant. Such wild allegations without basis do not have to be contradicted. Dr. Vaidya has been advising him tablet Glynase as could be seen from his prescription dated 13.10.1994. Dr. Vaidya is an M.D. and a Diabetologst. It is not the case of the appellant at the patient was administered insulin on any date prior to his admission in the hospital. A careful study of the expert opinion given by Dr. Chandra indicates that it is a verbatim support of the narration given in the complaint filed by the appellant. Dr. Athale in his deposition has stated that Dr. Chandra has never seen the patient himself nor did he conduct the post-mortem on the body of Patni. He had no knowledge and experience in Neurology. He also submitte that it is for the treating doctors to decide as to when the CT Scan had to be done. He disagreed with the contention that the machine was out of order. Analysis of evidence: For appreciating the contentions, let us now try to analyse the deposition of Dr. Chandra with that of Dr. S.A. Vaidya, Dr. Sanjay Gujral, Dr. Santosh Pandhye and Dr. Sunil Athale. Dr. Chandra has given an extract of the analysis as under: "It is on record that Dr. Vaidya was treating the deceased for last ten years and it is established by him that the patient was suffering from hypertension, diabetes and Dr. Vaidya was also aware that the deceased a known case of CVA right Hemiparesis. The deceased gave enough time i.e., at least 36 hrs. before his death for the management of diabetes. Fructose IV 5% was being given daily as a routine. It is accepted that fructose does not in small quantities raise blood sugar level, but when blood sugar went on a higher side and the patient became acutely ill i.e., diabetic crisis, giving insulin was the need of the hour, more so, when the deceased was showing other complications. .............................. Oxygen inhalation: This was only ordered on 29.7.1995 at 17.00 hrs."

Dr. Athale after the C.T. Scan on 29th July, 1995 admitted that small infarct in brain stem may not be observed in the C.T. Scan and presuming that the crisis was the result of infarct in the brain stem, advised to give heharine. Why oxygen was not given is an important point to be considered as gross negligence by any standard literature in the field. The points brought out on the basis of the facts drawn and analysed and further correlated from the medico-legal aspects, it appears that there was a negligence, that resulted in precipitating the death".

As against this, Dr. S.A. Vaidya, the Physician and Diabetologist having a decree of MD in medicine who was the personal Physician of Patni for last about 10 years before his death, has stated in an affidavit that Shri Patni was extremely obese (fat) and was suffering from Diabetes Mellitus and hypertension for last ten years. Shri Patni had old right-side Spastic Hemiparesis and large non-haemorrhagic infarct several years back. He was on continuous medication for the control of his diabetes, hypertension and allied complications of old infarct.

THAT on 25.7.1995 he was informed by the family members that late Shri Patni is feeling giddiness, vertigo, heaviness of right side limbs since 24.7.1995 and the vertigo was changing with the posture. On inquiry he was informed by the patient that he could not observe necessary discipline of regular medicines prescribed and diet control. He was also informed that intermittently, he used to get these exacerbations of symptoms because of non-compliance with the medicines prescribed and lack of control on his diet. He was also a known case of obesity and for these symptoms, earlier he was admitted in ICCU of Uni Diamond at Indore and thereafter he was admitted to Curewell hospital at Indore. He further stated "I had thoroughly clinically examined Shri Patni and found no fresh neurological deficit except for vertigo on change of posture. The ECG of patient was also done and that revealed LBBB (Left Bundle Branch Block) which was not present in his past record. Seeing the nature of the complaint and considering his past history, I had advised hospitalization. Shri Patni and his family had very good relations with the proprietor of Apollo Nursing Home, Indore and so, they expressed their willingness for admission in the said Nursing Home. Since the said Nursing Home had all necessary diagnostic facilities including well equipped pathology lab, X-ray CT Scan, etc. and facility of ICCU I expressed my no objection in Shri Patni''s hospitalization in Apollo Nursing Home". He further stated that during hospitalization from 25.7.1995 to 27.7.1995, the condition of patient Patni remained stable and his diabetic status was under thorough control. On 28th July, 1995, the patient developed hallucination, which was immediately reported to me and Dr. Athale. The opinion expressed by Dr. H. Chandra in his affidavit dated 26.9.1998 is substantially incorrect and was denied. The allegation that the prescriptions given by the examining doctors are not usually signed is incorrect. The prescription/order consists of 4 parts, the first part consists of doctor''s daily record, wherein the observations are recorded by the examining doctors and treatment is prescribed, second part consists of sister''s daily record, wherein the attending sister used to keep record of medicine administered from time-to-time as prescribed, the 3rd part is investigation chart wherein the chronological record of investigation actually performed is recorded and the fourth part is intake chart where record of daily intake of patient is recorded.

HE has also referred to following para from a medical text "Fructose, a ketohexose, is used parenterally as a carbdrale nutrient. It is converted to liver glycogen and metabolized rapidly than dextrose, without requiring insulin, and that may be utilized in diabetic patients. It is indicated in patients requiring that replacement and caloric feeding, contraindicated in hypoglycemia for which dextrose should be used" (Remington''s Pharmaceutical Sicence, 16th Edition, Page-972). Next, Dr. Sunil Athale who is MD in medicine and also DM, Consulting Neuro-physician in the reputed Chaithram Hospital and Research Centre has stated that "I had recorded details of my examination on the treatment papers of the Nursing Home and according to my assessment the patient had no new neuro-deficiency and my conclusion was that the patient had positional vertigo which does not adapt nor fatigue in presence of Diabetics Mellitus and old stroke. On clinical examinaion I had suspected posterior circulation ischemia. The blood sugar of the patient was under reasonable control at the time of my clinical examination as per the reports produced before me and I had increased dose of Stugeron and did not make any change in the remaining treatment prescribed by Dr. Vaidhya, O.P. No. 4." "That I had again seen the patient on 29.7.1995 between 9-10 a.m. and the patient complained of breathlessness and on this complaint I immediately made a thorough clinical examination of the patient and found that his urinary bladder was extremely distended and since the same was the most apparent cause of breathlessness, I immediately directed the duty doctor to empty the bladder with catheter. I had also advised CT head, ECG X-ray chest and RBS. Urine sugar + Acetone. I had also advised injection heparin 5000 units bd (two times in a day) subcutamously. I had also instructed the duty doctor to report me the findings of the CT Scan. After report of CT Scan I was reported that the patient is feeling difficulty in swallowing and after discussions with Dr. Vadiya I had advised to give full dose of heparin i.e., injection heparine 5000 units q.i.d. (4 times in a day) 6 hourly. The symptom and signs shown in the patient were pointing towards brain stem infract and most of the times the same cannot be located even in the CT scan and the same has happened in the case of the patient. Since the breathlessness reported to me was due to bladder distention there was no need for artificial oxygen and as is evident from the treatment papers that after catheterisation the complaint was subsided".

Findings : In our view, it would be difficult to rely upon the affidavit of Dr. Chandra which is contrary to the evidence led by the expert doctors who treated the deceased. Dr. Chandra could not be cross-examined because of his death. Further, it is clear from the qualifications and experience mentioned in his Bio-data that he had no clinical and surgical experience. Secondly, he had neither seen the patient nor had conducted post-mortem on the body of the patient. As against his affidavit, the depositions of a highly qualified Diabetalogist and a Neuro Surgeon have to be seen. The medical history of the complainant reveals that he had been a diabetic for more than a decade before his death. He suffered from obesity also.

DR. Vaidya who was his personal physician has deposed that Shri Patni was suffering from extreme Obesity and hypertension for a decade before his death. It is clear that the patient did not observe necessary discipline of regular medicines prescribe and diet control and accordingly earlier he was admitted in the ICCU of Uni Diamond at Indore and thereafter he was admitted to the Curewell Hospital at Indore. Mr. Patni was non-insulin dependent patient and all required medications were given to him in the hospital apart from conducting clinical and pathological tests from time-to-time, as warranted. The patient was prescribed Glynase earlier and the same medicine was continued during his hospitalization in the Nursing Home. Further, as stated there are no inconsistencies in the sister''s daily records and elaborate records were maintained in the hospital.

DR. Pandhya being the duty doctor used to supervise nursing care of the patient admitted in the Nursing Home on the basis of reference made by the Physicians and Surgeons. This shows that a full-fledged doctor was there in addition to DR. Gujarati who is an MD in medicine. This indicates that there was no death of medical and paramedical care in this Nursing Home. DR. Athale who is not only MD but DM in Neurology had treated the patient, on a call received from the Nursing Home and he had deposed that the blood sugar was under control and there was no neuro deficiency. Subsequently, when the patient complained of breathlessness, he made a thorough clinical check up and evacuated the distended bladder. Hence there was no need for administering oxygen. We, therefore, find that there is weighty evidence to prove that the appellant who was highly obese and was suffering from diabetes and such other diseases and was not strictly following the medical regimen advised by the doctor. He was admitted to the Apollo Nursing Home which has a team of competent doctors on its roll and in addition highly qualified consultants available on call had treated the patient with due care. It is unfortunate that he died after a brief stay in the Nursing Home for which no case of negligence can be made out against either the Nursing Home or the doctors who treated the patient.

Accordingly, we see no reason to differ with the Order of the State Commission. We also find that there is no infirmity or illegality in the order passed by the State Commission. Therefore, the appeal is dismissed. No order as to costs. Appeal dismissed.