M.Srinivas vs RAMA THULASI

Z

THE complainant is a resident of Madras and is living with his parents for the past four years. He married Ms. Madhavi hereinafter called ''the deceased'' d/o B. Janardhana Rao r/o Eluru. While so, she conceived in November, 1995 and it was informed to her parents at Eluru. Though all medical facilities are available at Madras, her parents wished that she should be with them being the first pregnancy. Accordingly indifference to their wishes the complainant agreed to send her to her parents in December, 1995. During her stay at Madras she was regularly examined by Dr. Republica Sridharan, T. Nagar, Madras. From December, 1995 onwards she was regularly visiting the first opposite party, hereinafter called ''the doctor'' who is also her family doctor. While so, the wife of the complainant met the doctor on 5.6.1996 for complaints of uneasiness, loss of appetite, vomitting sensation and not being able to pass urine freely. She visited again on 7.6.1996, 10.6.1996 and 14.6.1996. As there was no improvement scan of Gravid Uterus was conducted which showed foetus of 36 weeks. During the night of 15.6.1996 the patient developed severe pains and she was rushed to the clinic of the first opposite party doctor whereupon the latter admitted her for observation. But on examination the doctor opined that there is no cause for anxiety. On 16.6.1996 the doctor after going through the Gravid Uterus report informed that caesarean section has to be resorted to. Accordingly the said operation was performed at 1.00 p.m. and a female baby was born. After the surgery the doctor informed the parents of the deceased that she found that the patient was suffering from jaundice at the time of operation and shouted at them for not informing her of the same.

On receiving information about these developments the complainant reached Eluru by 12.00 mid-night on that day. After caesarean the patient was still unable to pass urine which was accordingly reported to the doctor who informed that it is not a problem. On 18.6.1996 at about 8.30 a.m. the complainant and his father rushed to the doctor and expressed their fear seeing the condition of the patient. The doctor informed them that the patient was not reacting to the treatment and recommended to try Ayurvedic pills which were brought by her. The complainant thereupon requested her to consider whether there was any process possible to remove the urine from the patient who had not passed urine for 48 hours and was bloating heavily. The complainant then requested the doctor to take second opinion from Dr. Venkat Rao, a specialist in these cases working in Medwin Hospital, Hyderabad, which suggestion was rejected by the doctor. However on being persuaded by the complainant and their relatives, the doctor advised them to shift the patient to Rajahmundry to one of her relations'' nursing home for dialysis. Finally she agreed to shift her to Vijayawada, a nearer place to the second opposite party hospital. Before shifting the doctor examined the patient and finding pulse rate being low and B.P. dropping, gave the patient some injections. She also gave a letter addressed to the second opposite party with details of treatment given by her and the present condition of the patient. Accordingly the patient was shifted to Vijayawada by hiring an ambulance and admitted in the second opposite party Poly Clinic at 4.00 p.m. on 18.6.1996 and the second opposite party doctor on examination gave her oxygen, saline and expressed that there is almost no hope of survival. The patient did not respond to the treatment given by him and finally breathed her last at 00.20 a.m. on 19.6.1996 in the second opposite party clinic.

ALL this happened due to the sheer negligence on the part of the doctor as she did not take proper care and caution at the time of operation as well as during post-operative period. The doctor had done caesarean whether it is necessary or not, only for the sake of money. Even during the post-operative period also, the doctor did not evince due and proper care. It is a clear case of the doctor failed to identify the problem at the right time and failed to take necessary steps to cure the patient. Conducting caesarean without taking necessary preparational tests to correctly visualise the patient''s condition is deficiency in service. The complainant and his in-laws have spent more than a sum of Rs. 1 lakh for treatment of the deceased. The child has become an orphan and lost the love and care of her mother. He too suffered mental agony and loss of his life partner. The complainant, therefore, claims a compensation of Rs. 20 lakhs. In the written version filed by the first opposite party it is stated that the parents of the deceased were known to her since 13 years. The deceased came to her nursing home for the first time on 10.12.1995 for medical check-up when she was in her second month of her second pregnancy. The report of urine examination was positive for pregnancy. Other tests like urine for culture and sensitivity, blood group, V.D.R.L., G.T.T. were all conducted and the reports are within normal limits. She prescribed medicines for maintenance of pregnancy and for prevention of recurrence of abortion. She is obese. She was coming to the nursing home for routine check-up and suitable medicines were being prescribed. On 5.6.1996 she came to the nursing home for fortnightly check-up. Urine test revealed that albumin and sugar were nil. She was prescribed medicines and advised to come after one week. On 10.6.1996 she came to the nursing home with painful urination. Her B.P. was 140/100 and suspected urinary tract infection. In view of this problem she was advised to be admitted in the nursing home. But she preferred to go home which is close-by. Thereupon the doctor advised her to take antibiotics for arresting urinary tract infection and also prescribed medicines for controlling B.P. for five days. Accordingly on 14.6.1996 she came back and the examination revealed that her B.P. was normal and she was relieved of urinary tract infection. She was advised ultrasonography of Gravid Uterus to assess the foetal well-being and to know the presentation of the foetus. The report revealed single live foetus with vertex presentation. She also complained of heart burn and medicines were prescribed for this problem.

THE patient was brought to the nursing home on 15.6.1996 with complaint of abdominal pain since three hours. She was admitted in the nursing home for delivery. On 16.6.1996 at about 10.45 a.m. the doctor felt that there was no progress in labour and the foetus developed distress, hence decided to go in for emergency caesarean. Before commencing surgery urine had to be removed to empty the bladder to avoid complications during surgery and at that point of time the doctor noticed that urine was yellow and jaundice was suspected. Immediately urine and blood samples were collected and sent for examination to the laboratory. After conducting test for bleeding and clotting time she proceeded with caesarean operation and a distressed female baby was delivered at 12.15 p.m. She received the urine and blood reports at 3.00 p.m. which are positive for jaundice. Dr. Republica Sridharan of Madras called her on phone on that day at the instance of the complainant and the doctor informed him the line of treatment adopted by her which is endorsed by him without any objection. As urine output is not satisfactory, treatment was given for the same on 16.6.1996. On 17.6.1996 at about 8.00 a.m. Dr. Sanjeeva Rao, Senior Physician in Eluru was called who examined the patient and advised urine and blood test. He also advised the patient to be shifted to higher centre for consultation with Nephrologist and Gastroenterologist. The allegation that the deceased complained of loss of appetite or vomitting sensation is incorrect. So also it is absolutely false that the doctor recommended Ayurvedic pills. It is equally false to suggest that the complainant asked the doctor to consult Dr. C.L. Venkata Rao of Hyderabad. Further the doctor advised them to take the patient to Rajahmundry is again false. There is also no nursing home belonging to the relations of the doctor at Rajahmundry. Vijayawada is nearer to Eluru and all medical facilities are available at Vijayawada.

THE allegation that the complainant and parents of the deceased spent a sum of Rs. 1 lakh is false. THEy paid Rs. 30/- per month and Rs. 200/- towards three days stay at nursing home. THEy paid about Rs. 3,000/- on 17.6.1996 towards all charges including surgery. Emergency caesarean was resorted to save the baby and the mother. All necessary tests were conducted and precautions taken in conducting the surgery.

THE doctor has insured herself with New India Assurance Company Ltd., under a policy for Professional Indemnity for Doctors and Medical Practitioners for a sum not exceeding Rs. 5 lakhs and the policy was valid from 13.2.1996 to 12.2.1997. THE claim of the complainant falls within the purview of the said policy. Hence the Insurance Company is a proper and necessary party to this complaint. As there is no negligence on the part of the doctor the complainant is not entitled to any relief in this complaint. The complainant examined himself as P.W. 1 and marked Exs. A-1 to A-29 while the first opposite party examined herself as R.W. 1 and marked Exs. B-1 and B-2.

The point for consideration, therefore, is whether there is any deficiency on the part of the opposite parties in treating before or after conducting caesarean section or while conducting the operation, if so, to what extent ?

AT the outset it may be stated that no specific allegation of deficiency in service is levelled against the second opposite party either in the complaint or in the evidence of P.W. 1. No material is also placed before us to show any negligence on the part of the second opposite party. Therefore, the complaint against the second opposite party fails. So far as the claim against the first opposite party doctor is concerned, it is not in dispute that the wife of the complainant was being treated by her from December, 1995 when she was in the second month of pregnancy. For routine check-up she was visiting the doctor. On 5.6.1996 the patient came to the doctor with complaint of uneasiness, loss of appetite, vomitting sensation, not being able to pass urine etc. However the doctor contends that she came on 5.6.1996 for fortnightly check-up and these complaints were not there. Therefore, the question is, whether the patient has visited the doctor with the above complaints or only for a routine check-up ?

THE prescription given by the doctor on 5.6.1996 marked Ex. A-11 throws light on this aspect. This Ex. A-11 is filed by the complainant himself. Seven items are prescribed, out of which 2 to 5 are either capsules or tablets while 1 and 6 are injections. Of course item No. 7 is a disposable syringe. This prescription shows that capsules or injections were prescribed for maintenance of pregnancy apart from iron, protein and B-complex tablets together with one tetanus injection. This prescription significantly shows that no medicine was prescribed for vomitting sensation, loss of appetite or for not able to pass urine etc. Added to this if really there was vomitting sensation, so many tablets would not have been prescribed. THErefore, we are of the view that symptoms as alleged by the complainant on 5.6.1996 cannot be true. The learned Counsel for the complainant contends that on 10.6.1996 the complainant approached the doctor again for the same problems, as there was no improvement. However the doctor contends that on that day she appeared before her for painful urination. When examined the patient B.P. was 140/100. She advised anti-biotics to arrest urinary tract infection and also prescribed medicines for controlling B.P. Here again the complainant filed Ex. A-12 the prescription issued by the doctor. It contains four items out of which item No. 1 is anti-biotic and item No. 4 is for B.P. Items 2 and 3 are prescribed to reduce acidity in urine and to relieve pain. Therefore, we are of the opinion that even on 10.6.1996 the symptoms mentioned by the complainant are not existing. The first opposite party doctor contends that medicines were prescribed on 10.6.1996 for five days and, therefore, the complainant had visited on 14.6.1996. According to the complainant, the same symptoms persisted even on 14.6.1996. The contention of the first opposite party doctor on the contrary is that when she came after five days on 14.6.1996, her B.P. was normal and relieved of urinary tract infection. Ultrasonography of Gravid Uterus was advised to assess the foetal well-being and to know the presentation of foetus. The report revealed single live foetus with vertex presentation. The patient complained of heart burn and the first opposite party doctor prescribed some medicines, as seen from Ex. A-14 prescription. Therefore, six items of medicine prescribed on 14.6.1996 under Ex. A-14 do not support the case of the complainant that she was having symptoms of loss of appetite etc., as alleged by the complainant. The opposite party doctor accordingly suggested anti-biotics to continue for two more days, apart from other drugs for maintenance of normal pregnancy. Therefore, we do not find any substance in the contention of the complainant that the patient was not treated for the symptoms complained of by her.

THE next question is, whether caesarean section was ill-advised as contended by the complainant?

IT is the contention of the complainant that caesarean section was necessary or not the first opposite party doctor used to do caesarean operations for the sake of money and this is the general opinion among the local people. IT is admitted that the complainant''s wife started experiencing heavy pain from 15.6.1996 and she was taken to the first opposite party doctor on 15.6.1996. On examination and after going through the Gravid Uterus report she advised caesarean section and it was accordingly performed on 16.6.1996 at 1.00 p.m. The first opposite party admits that the patient was brought at 10.30 p.m. on 15.6.1996 to her nursing home and she was put under observation for progress of labour. However she noticed on 16.6.1996 at about 10.45 a.m. that there was no progress and the foetus developed distress. As there was no alternative she has to elect emergency caesarean. The case sheet Ex. B-1 shows that the patient complained of pains since 3 hours by the time she was admitted at 10.30 p.m. It is also recorded that uterus acting mildly every five minutes. For every two hours the condition of the patient was noted. By 10.15 a.m. on 16.6.1996 it was noted U.T. acting well. FHS 126 p/mt. Irregular Bladder drawn-up. Membranes ruptured. Meconium stain liquor. By 10.45 a.m. the following notings were made. "FHS 110 p/mt. irregular Thick Cervical Lips, Loosely handing not well applied to the PP. Thick Meconium Stained Liquor ? Occipito Posterior Advised Emergency Caesarean."

In view of foetal heart sound had come down to below normal, thick cervical lips, thick meconium stained liquor, Occipito Posterior conditions, the first opposite party doctor decided to go for caesarean to save the foetus from distress. We cannot find fault with this procedure. There is absolutely no material placed by the complainant that these symptoms are not present at that time or the procedure adopted by the doctor is unwarranted. Even the paediatrician recorded in the operation notes as seen from Ex. B-1 "Meconium stained, heart rate less than 80 Cyanotic, while suctioning meconium stained liquor, child grimaced and feeble respiration". Therefore, the observation of the paediatrician shows that the child was in distress. These notings also lend support to the timely decision taken by the doctor. Therefore, we cannot endorse with the objection of the complainant that there is deficiency in service on the part of the first opposite party doctor in electing to go for caesarean section in these circumstances.

The next contention of the complainant is that though the complainant''s wife was periodically visiting the first opposite party doctor for check-up, the doctor failed to diagnose the problem correctly and advise proper treatment. In other words his contention is that the first opposite party could not detect that his wife was suffering from jaundice which is a serious deficiency.

TO substantiate this contention, it is pointed out that painful urination is one of the symptoms of jaundice. It is countered by the first opposite party doctor that for jaundice painful urination is not a symptom and in pregnant woman urinary tract infection is most common. It is also contended that there was no symptoms of jaundice till 16.6.1996. Only when 300 ml. of urine was drained out from the abdomen of the patient it was noticed that urine was in yellow colour, as such jaundice was suspected. On 16.6.1996 the operation notes show that Bladder catheterised about 300 ml. high coloured urine drained. Jaundice suspected : Eyes not yellow. In the anaesthesia record also the anaesthetist recorded sclera normal (eyes). But high coloured urine. The learned Counsel for the complainant submits that the first opposite party doctor though noticed that the patient was not able to pass urine, conducted caesarean section and failed to treat the patient for this complication but went ahead with the caesarean and finally unable to save the patient advised shifting of the patient to Rajahmundry for dialysis as such facilities are not available at Eluru. We have to see how far this contention merits acceptance.

IT is true that the patient was not able to pass urine on 15.6.1996. As per case sheet Ex. B-1 Urine Albumin Sugar nil. In the operation notes after surgery at 3.00 p.m. it is noted "informed about jaundice risk explained to parents because of jaundice and also about bad prognosis". On 17.6.1996 at 9.05 a.m. blood urea is noted as 27 mgs. and serum creatinine as 0.8 mg. According to Harrison''s Principles of Internal Medicine, 15th Edition, indications for dialysis are shown as when blood urea is 100 to 150 mg. or creatinine 8 to 10 mg/dl. On 17.6.1996 both the counts are below this range. Even on 18.6.1996 blood urea level is 32 mg. while creatinine level is 1.2 mg. which are also far below the range for recommending for dialysis. Ex. A-18 which is a blood report of the complainant''s wife dated 17.6.1996 issued by Ambica Clinical Laboratory & X-ray Clinic, Eluru also shows the blood urea at 27 mgs% and serum creatinine 0.8 mgs%. So also he same laboratory report under Ex. A-27 dated 18.6.1996 shows blood urea at 32 mgs% and serum creatinine at 1.2 mgs%. From this it is clear that the blood urea level and serum creatinine levels increased day by day from 17.6.1996 but they were below the range for recommending dialysis. Even in Ex. A-28 the death summary issued by the second opposite party among the treatment it can be seen that no dialysis was done. Hence we are of the opinion that not sending the patient for dialysis cannot be termed as negligence or deficiency on the part of the first opposite party. The other question that remains for consideration is, whether the first opposite party failed to notice jaundice between 5.6.1996 to 14.6.1996 as between those dates the patient was came for check-up by the first opposite party ?

IN Davidson''s Principles and Practice of Medicine, Sixteenth Edition page 509, Clinical features for the onset of jaundice it is stated that common manifestations of an acute infectious disease and include chills, headache and malaise and anorexia (loss of appetite) etc.... Dark urine and a yellow tint to the sclerae (eye) herald the onset of jaundice.

IN Mudaliar and Menon''s Clinical Obstetrics, Ninth Edition page 132, it is stated that in pregnancy, the incidence as reported is eight times higher than in the non-pregnant. The stools become pale and clay coloured and the urine dark in colour. The liver becomes enlarged and tender, and clinical jaundice sets in. IN non-fatal cases, the patient recovers in 2.12 weeks... IN severe cases, abortion, premature labour, postpartum hemorrhage, hematuria and renal failure are often seen. Hepatic coma is a fatal complication... There is no specific treatment. Rest in bed is most important and should be insisted on till all signs and symptoms disappear.... More mothers die during pregnancy due to jaundice than due to many other medical and obstetric complications. We may point out that the colour of the eyes did not show any indication of jaundice. Even urinary tract infection as contended cannot be a decisive factor in diagnosing the jaundice.

Differix Internal Medicine shows usual causes for Dysuria are urinary tract infections, urethral stricture, after indwelling catheter, foreign body in bladder or urethra etc.

AS already seen from the above authorities that common clinical features of jaundice or prodromal symptoms usually precede the development of jaundice with chills, headache, malaise (a vague feeling of bodily discomfort), Gastro intestinal symptoms, anorexia, nausea, vomitting and diarrhoea besides dark urine and yellow tint to the sclerae (eye). AS already seen there is no yellow tint to the eye, no chills, no headache. Though the complainant alleged that there was a complaint of vomitting sensation but vomittings were not complained nor diarrhoea, anorexia i.e., loss of appetite though alleged to have been complained as per the complaint but we find that it is not true. So also the patient was not able to pass urine freely was complained on 5.6.1996 as per the complaint, we found that this allegation also is not true. She complained of painful urination on 10.6.1996 only, for that medicine was prescribed and by 14.6.1996 she was relieved of this symptom. The patient complained of heart burn on 14.6.1996 for which also the doctor prescribed some medicines. Therefore, the allegation that the doctor did not diagnose the problem properly is not correct. The symptoms of jaundice can be diagnosed clinically as seen from the said authority and she did not find any symptoms for jaundice upto 14.6.1996. The complainant started experiencing heavy pain from 15.6.1996 and she was admitted in the clinic of the first opposite party at 10.30 p.m. Therefore, it is not possible to send for urine test on that day. As foetus is in distress by 10.45 it is decided to go in for caesarean to save the child. Even on 15.6.1996 Ex. B-1 case sheet shows that urine albumin sugar nil. Before commencing surgery urine was removed to empty the bladder to avoid any complication in the surgery and at that point of time the doctor noticed that urine was yellow and jaundice was suspected. Blood and urine samples were collected and sent for examination to the laboratory which confirmed jaundice.

AS already seen there is no specific treatment except rest in bed till all signs and symptoms for jaundice disappear. Hence we do not find that there is any deficiency in the line of treatment adopted by the first opposite party. It may be relevant to notice that death summary Ex. A-28 shows the probable cause of death as cardio respiratory arrest with Hepato renal shut down with ? Septaocemia (infection of blood) with ARDS and Hepato (liver). Renal failure is not shown as the cause but only shut down is shown as the probable cause. Therefore, from the above discussion we are of the opinion that the complainant failed to establish any negligence on the part of the opposite party No. 1. There was no clinical manifestation of jaundice between 5.6.1996 and 14.6.1996 which the opposite party No. 1 failed to notice. She diagnosed the problem of painful urination as urinary tract infection for which medicines were given and she noticed improvement by 14.6.1996. The patient was brought to the first opposite party clinic on 15.6.1996 as she got severe abdominal pain and admitted her at 10.30 p.m. Oliguria (low urine out-put) was the complaint at that time. It is not a sure indication of jaundice. However urine test was conducted on 16.6.1996 which showed positive. Therefore, we cannot hold that the doctor failed to diagnose the disease as jaundice till then or this shows deficiency in service on her part.

FOR all these reasons, the complaint fails and is accordingly dismissed, but in the circumstances without costs. Complaint dismissed.