NEELA SRIDHAR vs DURAI RAJENDRAN

-COMPLAINANT''s case is that the complainant''s wife Malar Vizhi did not have her period for three months and, therefore, suspecting that she had conceived and to have it confirmed, the complainant took her to the opposite party on 20.3.1995 where the opposite party is running a clinic under the name and style of "Priyadarsini Clinic". The opposite party after examination informed that the complainant''s wife had not conceived and if she is given an injection, the period will be regulized and saying so, she administered injection namely "Life" and also prescribed certain medicines, for which, she charged and collected necessary fees. After the treatment and after taking the tablets prescribed by the opposite party, there was deterioration in the health of the complainant''s wife, who was otherwise a healthy woman. She became reduced and emaciated and looked enervated. Therefore, on 12.4.1995 he again took her to the opposite party, who prescribed certain tablets and assured that if she had it regularly, she will be all right. A fee of Rs. 25/- was paid on that day. The complainant''s wife began to have the tablets regularly but still there was no improvement and the sufferings of the complainant''s wife became more acute. Therefore, on 15.4.1995, he took his wife to the opposite party who suggested, after examining her, that if D and C is carried out, she would be all right and would conceive. She suggested to the complainant to admit his wife in her clinic on that day itself and said that the operation would be carried out on 16.4.1995 in the afternoon. On 16.4.1995, accordingly she did the D and C procedure and after administering injection and prescribing medicines at 6 p.m. on that day, she discharged the complainant''s wife from the hospital though the complainant''s wife was still under sedation. The complainant then paid a sum of Rs. 300/- towards D and C charges and admission fees in the hospital. Even after the complainant''s wife came home, she was not all right, she had vomitation and fever. Therefore, the complainant took his wife to the opposite party on 18.4.1995. The opposite party immediately admitted her in the clinic and prescribed certain course of treatment. But still the health of the complainant''s wife began to deteriorate and on 19.4.1995, it became worse. The complainant''s wife could not even pass urine and she fainted and became speechless. Therefore, the opposite party suggested the complainant to bring Dr. Kamalakkannan from Aranthanki. Dr. Kamalakkannan from Aranthanki came and examined the complainant''s wife and immediately informed the complainant to take his wife to Madurai Menakshi Mission Hospital and told him that if he went there, her life will be saved. He also gave a letter of referral to the Hospital at Madurai. Immediately the complainant engaged a taxi and took his wife to Madurai and admitted her in the hospital on 19.4.1995. The doctors took various tests and said that the complainant''s wife was suffering from diabetic and without testing the same, D and C had been done and, therefore, as a result of the same, the wound had become septic and there was excess bleeding and the urination problem has set in and thus the complainant''s wife had been driven to a coma and hypotension and, therefore, she is in a critical stage and they would do everything to save her life. In spite of their best efforts, the complainant''s wife died on 20.4.1995. On account of the carelessness, negligence, and indifference of the opposite party in carrying D and C without making preliminary tests, the complainant''s wife had the septicemia and bleeding as a result of which hypotension and respiratory problem had set in resulting her death. The opposite party did not take any steps to save the life of the complainant''s wife. Therefore, there is deficiency in service on the part of the opposite party. Hence, the complainant prays for a direction to the opposite party to pay a sum of Rs. 2 lakhs for the death of his wife and loss of companionship, mental agony and hardship and a sum of Rs. 54,000/- towards medical expenses.

THE opposite party has submited a version contending thus: THE complaint is not maintainable. On 20.3.1995 for the first time the complainant brought his wife to the opposite party to test whether she was pregnant since she had no menstruation for the period of 3 months. On this, it was found that she was not pregnant and certain prescriptions for the resumption of the period was given to the complainant''s wife. She was asked to come back on the 5th day after the period restarted. On 27.3.1995, the complainant''s wife came and informed that she had period but requested that a D and C may be done. THE opposite party thought that some time lapse is necessary and, therefore, advised the complainant to bring his wife after 3 weeks. On 13.4.1995 the complainant with his wife came and requested the opposite party to do the D and C for which the opposite party agreed and fixed the date as 15.4.1995. On 15.4.1995 the complainant''s wife came accompanied by her sister-in-law. She was advised to have her admitted in a Government Hospital where facilities for performing D and C are available as there was no facilities in the Primary Health Centre in Singavanam. But the patient was not anxious to have done it at Government Hospital and requested the opposite party to get her admitted in her Nursing Home and also requested the opposite party to perform the D and C. Thus out of humane consideration, the opposite party agreed to perform the D and C. Before the performance of the D and C, all necessary tests like blood -test and urine-test, etc., were taken. THE patient had her blood test done in Sri Babu Clinical Laboratory. In addition, blood test and urine test were done at Sabari Laboratory, attached to Priyadarsini Poly-clinic, according to which Hb was normal and Rh negative. THEre was not even trace of sugar or albumin. THE health condition of the patient was found to be normal. Accordingly, D and C Endometrical biopsy was performed on the patient on 15.4.1995 and it was successful. This D and C (Endometrical biopsy) was done only to facilitate the fertility of the patient for creating a favourable condition for her future conceivement in uterus. D and C was done according to the procedure. THE patient was kept under medical observation till 6 p.m. on that day. She was in normal condition and then she was willing to go to her house and the complainant was insisted to take her home. Hence, she was accordingly discharged. It is not true to say that she was sent back prematurely against her Will. THE patient was advised to come back after two days. She came back only on 18.4.1995 afternoon accompanied by her sister-in-law and complained of pain in upper abdomen and right loin and vomiting. THE opposite party after examination found that the cause of pain was not due to the after effect of D and C since no pain emanated from that region of the body. THE opposite party suspected that the pain might be due to some other cause and was of the opinion that the cause of the pain might be due to renal problem, a cause which unconnected with the performance of D and C. However, the opposite party wanted to confirm her views by a second opinion from another doctor for which she requisitioned the service of Dr. Kamalakkannan. Dr. Kamalakkannan on examination of the patient, confirmed the opinion of the opposite party and advised the patient to have clinical investigations including x-ray, blood test, urine test, etc. THE patient had all the tests done at Swathi Lab., Arantangi at her choice and these tests revealed that her condition was normal in all respects and there was no symptom of diabetes. However, Dr. Kamalakkannan advised the patient to have consultation and check up at Menakshi Mission Hospital and Research Centre at Madurai since the patient might have had some inherent metabolic disease and the patient was sent immediately. THE patient was admitted in Meenakshi Mission Hospital and Research Centre at Madurai. It is learnt from inquiry that the patient had refractory circulatory failure and expired. It is also learnt that laparatomy was conducted which proved to be negative thereby meaning that the condition of the uterus was normal and that the performance of D and C has not caused any harm. THE performance of D and C was not at all responsible for the deterioration of the patient. THEre was any negligence in treating the complainant''s wife. THE allegation of the complainant that the patient and the complainant were ignorant of the diabetes is false. This is a new allegation projected after the reply notice of the opposite party. It does not find place in his notice dated 5.6.1995. In his complaint sent to the Collector, Pudukottai District, the complainant alleged that death had occurred on account of the defective performances of D and C. Series of tests done prior to and after the performance of D and C did not reveal any symptom of abnormality. It is a possible inference that the patient had diabetes under control by medication which they had totally suppressed to the opposite party. Since the clinical test did not reveal any symptom of diabetes, it cannot be expected for any doctor to know that the patient is suffering from diabetes that too such young age. THErefore, if the treatment for diabetes was given in Meenakshi Mission Hospital and Research Centre at Madurai, the disease which was suppressed by medication would have surfaced due to the patient''s negligence of discontinuing the drugs which perhaps used without knowledge of the opposite party or the diabetes might have suddenly surfaced as acute diabetic keto acidosis. Proper treatment was given by the opposite party. THE other allegations made in the complaint are denied. THE opposite party is not liable. THEre was no negligence or carelessness. THEre is no deficiency in service. Hence, the opposite party prays the complaint be dismissed. The lower Forum by its order dated 24.12.1998 directed the opposite party to pay a compensation of Rs. 1 lakh with interest at 12% from 22.8.1995.

Aggrieved by the said order, the present appeal is preferred by the opposite party.

IN this case, certain facts are not in controversy. Therefore, we can rush through the same so that further discussion would stand facilitated. The complainant''s wife was admitted in the hospital of the opposite party where she underwent D and C on 16.4.1995. Her condition became worse and a doctor from Aranthangi was called in for second opinion and on his advice, she was rushed to Meenakshi Mission Hospital and Research Centre, Madurai on 19.4.1995. She died at the said Meenakshi Mission Hospital on 20.4.1995. The complainant would submit that necessary tests were not made and that even without verifying whether she was suffering from diabetes or not, D and C had been done. It is not necessary for the purpose of our discussion to go into all those reports to find out whether the deceased was suffering from any diabetes and without taking note of it D and C had been done. The D and C is only a minor surgery or a procedure carried out by the doctor to facilitate conception by the woman patient who undergoes the same. The records produced in this case show that necessary blood and urine tests were carried out before ever D and C was undertaken to be done. IN fact the deposition of the doctor who has been examined as a witness for the opposite party/appellant is that the death would have been due to sudden increase in blood sugar which according to him may be due to D and C. It was diagnosed as Diabetic Keto Acidosis and refractory circulatory failure (cardiac arrest). IN the book ''Endocrinology and Metabolism Clinics of North America" at page 683, a reference is made to Diabetic ketoacidosis. While referring to the mortality and epidemiology, this textbook reads as under: "Patients with DKA of HHNS usually do not die as a result of hypertonicity or acidosis but succumb to a concurrent disorder that may have precipitated (e.g. myocardial infarction, sepsis, pancreatitis) or developed during the treatment of the metabolic and volume abnormalities of DKA and HHNS. Some deaths occur as a clear compliction of therapy."

It further mentions that the annual incidence of DKA in the United States, as reported by the National Diabetes Data Group in 1995, was 4.6 to 8 episodes per 1000 diabetic subjects. It also mentions that it was estimated that 2% to 8% of all diabetic hospital admissions are for the treatment of DKA. The textbook further refers to accumulation in plasma resulting in increase in unmeasured anions accounting for an elevated plasma anion gap. Ketone bodies exert an additional significant urinary osmolar effect. IN addition, urinary ketoacids promote additional excretion of positively charged ions to maintain electrical neutrality. Renal excretion of glucose prevents the blood glucose concentration from rising above 500 to 600 mg/dL as long as renal function is preserved. The clinical presentation of patients with DKA often includes vomiting, thirst, polyuria, an altered sensorium, weakness, fatigue, abdominal discomfort, and air hunger. It also mentions that other important precipitating factors including myocardial infarction which may be silent in patients with long-standing diabetes, stroke, pulmonary embolism, acute pancreatitis, gastrointestinal bleeding, trauma, glucocorticoid use and severe emotional stress. It also refers to the management of diabetic ketoacidosis and how it should be corrected. Here the contention of the opposite party/appellant herein is not that the death took place suddenly and such occurrences are not uncommon, but the patient had long-standing diabetes which she concealed. But Ex. A-8 is the report on the blood test done on 18.4.1995. Ex. B-1 is the report of the blood test done on 29.3.1995, Ex. B-2 which is the report for the test done on 30.3.1995 and the test done on 15.4.1995. They all show that there was no blood sugar at all. The test done on 18.4.1995 shows that the random sugar test was at 126 mg for D1. Therefore all these tests clearly establish that the deceased did not suffer from blood pressure or blood sugar at any point of time. It is also to be pointed out that she was aged just 20 on the date of her death. There is no record produced nor any suggestion is made that her parents were suffering from acute diabetes or that she had a history of family diabetes. Therefore, in such circumstances, it cannot be stated that her blood sugar suddenly shot up. No doubt, from the discharge summary issued by Meenakshi Mission Hospital, we find that they have noted an increase in blood sugar level and this increase is definitely shown to be on the higher side. We have already referred to the textbook "Endocrinology and Metabolism Clinics of North America" relating to Diabetic Ketoacidosis which only shows that diabetic ketoacidosis will not set in suddenly. Therefore, it has set in suddenly and she had developed altered sensorism and hypotension and as there was a respiratory failure, she was intubated and put on ventilator and the patient died of diabetic ketoacidosis shock which brought about the refractory circulatory failure. IN this connection, the doctor from Meenakshi Mission Hospital has been examined. Of course, he is not the doctor who treated the patient, but he has spoken to the treatment given as seen from the case records. He is a consultant Nephrologist. Of course, some uncharitable comments have been made by the lower Forum stating that he has been purchased by the other side and that owing to professional affinity he has chosen to suppress the truth and speak to the case in support of the opposite party. But a reading of the evidence of the doctor does go to show that the remarks and observations are unwarranted. The doctor has given evidence from the records and he has been impartial in what he has stated. He has stated clearly in the course of cross-examination that because of D and C, blood pressure had shot up and he has further stated that there was bleeding found in the douglas pouch which is situated by the side of uterus and this bleeding could have been caused by D and C. He also states that he does not know from when the complainant was suffering from diabetes, but her pancreas must have been affected with virus suddenly and as a result of it she had become suddenly a diabetic. He has also answered the suggestion that they have noted in P-1 that respiratory circulatory failure could have been caused by the wrong procedure adopted in choosing D and C. He has further spoken to the fact that D and C is but a minor operation method which is adopted to clean the uterus and that there cannot be any cause for bleeding in the douglas pouch for a normal patient. He has further stated that sudden change in food habits or activities will not bring about acidosis hypotension or circulatory failure. The discharge summary reads as follows: "20 years old patient was admitted in deep coma with acidotic breathing and hypotension. There was history of D and C being carried out 3 days prior to admission following which she developed altered sensorium and Hypotension. Since the patient was in respiratory and circulatory failure, she was intubated and put on ventilator. Abdominal ultrasound showed suspected collection in pouch of douglas. She was taken up for laparatomy which proved to be negative. Diagnosis of Diabetic Ketoacidosis with shock was made and high dose insulin was started. Inspite of intensive management patient had refractory circulatory failure and expired." From the above discharge summary, we find it is stated in clear terms that the condition of developed altered sensorium and hypotension followed D and C. For, it is stated clearly that there was a history of D and C being carried out 3 days prior to the admission following which she developed altered sensorium and hypotension. Therefore, it is clear that following the D and C operation the patient developed altered sensorium and hypotension. "Following which" would mean coming after in time as a sequel to or that follows, that goes after. Therefore, it is clear from the very certificate that the condition of altered sensorium and hypotension developed as a sequel to D and C or as a result of D and C.

THE patient was a healthy patient just 20 years of age. She did not have any blood pressure or diabetes. She undergoes D and C at the hands of the opposite party. Within a day after the operation, the patient''s condition becomes worse, the opposite party advised the husband of the patient to bring in a doctor from Aranthangi who, after seeing the patient, states that she was in a very bad stage and that she should be immediately taken to the Hospital at Madurai. She was taken to the hospital at Madurai, but unfortunately she dies on the very next day. Even assuming that the death was as a result of diabetic ketoacidosis cardiac arrest, this diabetic ketoacidosis cardiac arrest had developed because of the D and C not having been done properly. THErefore, following the said minor surgery or procedure, as the case may be, the patient had developed altered sensorium and hypotension. This has added to the other complications ultimately leading to respiratory circulatory failure and cardiac arrest. We have already referred to the fact that there seems to be certain changes in the body chemicals. THE clinical presentation of patients with DKA includes vomiting, thirst, polyuria, an altered sensorium, weakness, fatigue, abdominal discomfort, and air hunger. THE duration of symptoms is usually relatively short, ranging from hours to a day or two, probably owing to the toxic effects of ketosis and acidosis. That is what has happened in this case thus affecting the life of a young woman. The opposite party has stated in the version that she suggested the patient to admit herself in Government Hospital where facilities for performing D and C are available and the Primary Health Centre, Singavanam where the opposite party was working had no such facilities. Thus, there is an admission in the version stating that there were no facilities in the place where she was working for performing D and C. It is further stated in paragraph 2 of the version that the patient expressed her desire to get admitted in a private nursing home and wanted the opposite party to perform D and C and that the opposite party agreed to the same and the patient herself chose to get admitted in the Nursing Home of Priyadarsini Polyclinic. The opposite party conveniently omits to mention that the said Priyadarsini Polyclinic is the Polyclinic run by her. She mentions about it in the version as though she had nothing to do with the same and that the complainant''s wife chose that Nursing Home and got herself admitted therein. This would show the working of mind of the opposite party. The opposite party admits in the version that the condition of the uterus was normal. She states that she learnt that the patient had refractory circulatory failure and expired. She also admits that the opposite party wanted to confirm her views and sought the second opinion from another doctor by name Kamalakkannan who also advised after examining the patient to have a consultation and check-up at Meenakkshi Mission Hospital. The opposite party has not produced any medical authority to show that in certain cases where D and C are performed, blood sugar would suddenly shoot up. The reason why the pancreas had been affected by bacteria and when it got affected, we have no answer. But on the other hand, the evidence of Dr. Sampathkumar is to the effect that the circulatory failure and hypotension could have occurred if the D and C had not been done properly. That the D and C had not been done properly is evidenced from the fact that collection of blood was seen in the douglas pouch. It is following the D and C these things had occurred. It is further clear from the very discharge summary issued by Meenakshi Mission Hospital which is marked as Ex. X-3. There is no other plausible reason given for the sudden onslaught of diabetic ketoacidosis. Therefore, the facts speak for themselves in this case. It is no doubt true that it being a case of medical negligence, it is necessary to adopt a cautious approach for arriving at a conclusion. The National Commission has also held in I (2003) CPJ 153 (NC), that when there is an allegation of negligence in surgery, in the absence of an expert opinion, the Commission cannot constitute itself a body and contradict statement of doctor. There must be some prima facie material, of course, in such cases, before ever we accused the doctor of negligence. It is true that doctors are not Gods nor they possess with a magic wand that can cure the patients of all illness. What all we have to see is whether the particular course and procedure adopted by the doctor for treatment of the particular disease or illness is one recognised and accepted everywhere and whether there is any failure on the part of the doctor in following the same. In this case on hand, the complainant has not, of course, examined any expert in evidence. But in our view, that is not necessary since the facts in this case speak for themselves. Besides, we have the very evidence of the doctor examined on the side of the opposite side which is suggestive of lack of care and negligence on the part of the opposite party in carrying out the procedure. In fact, the very discharge summary relied upon by the opposite party shows that circulatory failure and hypotension followed the D and C and it led to the other complications and ultimately to cardiac arrest. A normal young and healthy woman who neither suffered from any blood pressure or diabetes when she was at the age of 20, with a desire to have a child, suspecting something may be wrong with her reproductive organs, went to the opposite party to have D and C performed so that she may conceive and become a mother. But immediately after the operation or from the very next day of operation, her condition became worse that she had to be shifted to Meenakshi Mission Hospital, where she had breathed her last. These facts are vociferous enough to claim that there is some want of care and negligence on the part of the opposite party, and otherwise what had happened would not have happened. Therefore, the materials on record are sufficient to hold that there was some absence of care and duty in treating the patient.

NOW coming to the quantification, the lower Forum has granted a sum of Rs. 1,00,000/- as compensation though the complainant has asked for Rs. 2,50,000/-. The complainant has produced bills for the expenses incurred by him both at the opposite party''s hospital and in Meenakshi Mission Hospital and Research Centre, Madurai. The complainant has lost his wife at a very young age and thus he has been deprived of his companionship. He has lost her love and affection. It must have been a rude shock to him. Therefore, considering the nature of calamity, the age of the deceased and the circumstances, we do not find any reason to hold that the compensation awarded is on the high side.

IN the result, this appeal is dismissed, but in the circumstances, without costs. The order passed by the lower Forum will stand confirmed. Appeal dismissed.