N.J. Karnavat vs Patel Ishwarlal Mangalal and Ors.

P class="subparagraph">It is important for the doctors and medical establishments to properly maintain the records of patients for two important reasons. The first one is that it will help them in the scientific evaluation of their patient profile, helping in analyzing the treatment results, and to plan treatment protocols. It also helps in planning governmental strategies for future medical care. It is wise to remember that "Poor records mean poor defence, no records mean no defence." - - Author Joseph Thomas.

THE present Revision Petition has been filed before this Commission under Section 21(b) of the Consumer Protection Act, 1986 against the impugned order dated 12.3.2012 in Appeal No. 1468A/2007 passed by the State Consumer Disputes Redressal Commission (in short, ''State Commission''). The State Commission allowed the Appeal filed against the order in Complaint No. 279 of 1994 dated 9.1.2007 passed by the District Consumer Disputes Redressal Forum, (in short, ''District Forum''). Facts in brief are; On 8.12.1993 Mr. Patel Ishwarlal Manglal the complainant took his wife Pashiben since deceased (hereinafter referred as "Patient") for complaint of fever to the Dr. N.J. Karnavat (OP -1) at his Karnavat Hospital in Palanpur. He prescribed some medicines and gave injection, and called her after 10 days, again after 10 days some medicines continued. Thereafter, around 20th day, patient suffered body ache, and headache for which she again consulted the OP -1 who advised medicines and injections for further 3 days, but her health further deteriorated and she developed uterine bleeding. Again OP -1 was consulted, he advised urgent removal of uterus (Hysterectomy) on very next day. Hence, on 10.1.1994, she got admitted in Karnavat Hospital and the hysterectomy was performed by OP -1 Dr. Karnavat on 11.1.1994. During her post operative stay in the hospital she suffered abdominal discomfort, stomach pain, but OP -1 explained it as gas trouble and there was nothing to worry. The stomach pain went on increasing, hence on 20.1.1994, in the afternoon OP -1, performed emergency operation and resected decayed part of intestine, then assured the patient and complainant about early cure. But, unfortunately, the condition of patient did not improve, hence the OP -1 advised the relatives of patient to take her to the expert Dr. Rupesh Mehta, of Mehta Hospital at Ahmedabad. Accordingly, patient was taken to Mehta Hospital on 24.1.1994, where another operation on intestine was performed on 26.1.94 by Dr. Rupesh Mehta (OP -2). The OP -2 went abroad from 2.2.94 to 14.2.94 handing over the patient in hands of inexperienced junior doctors, hence there was no direct supervision by OP -2 which ultimately caused death of patient on 16.2.1994. Hence, the complainant filed the complaint before District Forum, Palanpur against the OPs alleging negligence on the OPs causing the death of his wife and prayed for the compensation for Rs. 5 lacs plus other reliefs. The District Forum dismissed the complaint. The complainant filed a first appeal before the State Commission, Ahmedabad, which was allowed on 12.3.2012, and directed the OP -1/Petitioner to pay compensation of Rs. 1,75,000 and costs of Rs. 5,000 to the complainant.

AGGRIEVED by the order of State Commission, the OP -1 Dr. Karnavat, filed this revision.

WE have heard Counsel for the petitioner, none present on behalf of complainant. There was a delay of 3 days in filing this Revision Petition. We condone this delay after perusing and hearing the reasons stated in the application for condonation of delay. The Counsel vehemently argued the matter, he submitted that the patient was a close relative of Dr. Karnavat, due to belief and confidence the patient approached him for the treatment. He further submitted that, the complainant has failed to produce any medical literature or expert medical evidence to establish the alleged link between the operation of the uterus and the onset of the condition of fecal fistula. We have perused the medical records, like prescriptions on file, also the evidences, cross -examination. It is very important to note few relevant dates to conclude this revision and those are 8.12.1993, 11.1.1994, 20.1.1994 and 26.1.1994. We have analysed the sequence of events as following: The hysterectomy was performed by OP -1 in Karnavat Hospital, Palanpur,

Again, after 9 days, on 20.1.1994, Dr. Patni, another surgeon, performed operation for intestinal obstruction in the same hospital and resected decayed part of intestine.

Further, the patient was referred on 24.1.1994 to OP -2 Dr. Rupesh Mehta, who performed another operation on intestine for fecal fistula on 26.1.1994 at Mehta Hospital in Ahmedabad.

IT is pertinent to note that, there are no medical records like the case sheet of Karnavat Hospital regarding detailed history of patient, the Operative notes of Hysterctomy and Intestinal resecion, the follow up treatment and relevant clinical notes. We have perused the drug prescriptions, which were illegible and one Ultrasound report of the patient issued by Ashirvad X -ray and Sonography issued by Dr. Rajendra Bhat dated 10.1.1994. If the patient had fever on and off, and was under treatment for more than 10 days, why OP -1 failed to diagnose the cause of fever at initial stage. Thus, his approach to the patient was casual one, because the patient was his relative. Without proper treatment of fever, he proceeds for Hysterectomy, what was the urgency? We are unable to subscribe whether patient was fit for operation or not. We are surprised that there was a dearth of Gynecologists in Palanpur? The OP -1 is a Surgeon, how could he decide about need of hysterectomy, without Gynecologist opinion. The USG report clearly shows that the Uterus, ovaries were normal, no cyst or any growth. No clinical notes or cogent evidence available about the indication of hysterectomy, thus OP -1 cannot take a defence on the basis of as patient was his relative. Thereafter, on 20.1.1994, Dr. Patni, a Surgeon has performed operation for intestinal obstruction and resected a loop of decayed intestine; but it was a failure, hence the OP -2, Dr. Rupesh Mehta operated the patient at Ahmedabad on 26.1.1994 and the intestinal histopathological report issued by Pathologist Dr. Bhaskar Vyas revealed that, it was "Typhoid Ulcer - perforation". The HPE report (relevant findings) are reproduced as below:

A specimen of right hemicolectomy with small intestine for the histopathological examination.

The Section prepared from the perforated area of ileum show on H -E stain. Histology of enteric (typhoid enteritis) with focal areas of haemorrhage and necrosis with evidence of perforation in the wall of ileum.

Conclusion: Typhoid enterities with perforation, No koch''s lesion seen. No MALIGNANCY DETECTED.

HENCE , it clearly proves that, the patient was suffering from Typhoid since 8.11.93, which the OP -1 failed to diagnose the case of fever, and not treated it for initial 20 days i.e., till the hysterectomy. The hysterectomy operation took place while the patient was suffering from Typhoid (enteric) fever. The death certificate issued by OP -2 clearly establishes about progress of disease, it is reproduced as: This is to certify that Pasiben Ishwabhai Patel expired on 15.2.94 at 10.35 p.m. due to cardiopulmonary arrest.

She had fecal fistula, she was operated elsewhere for hysterectomy and intestinal obstruction she was admitted under our care on 24.1.94 Right hemicolectomy was performed. Biopsy report was enteric perforation, it was again followed by fecal fistula.

We have perused the medical bills and receipts; but we don''t find any receipt for charges collected by OP -1 towards Consultation, Hysterectomy Surgery and hospitalisation. We may believe the OP -1 has extended his services free of cost to his relative, but there is no evidence that services of Dr. Patni, the USG reports were done at free of cost. It was a team work at Karnavat Hospital, hence, OP -1 cannot claim exemption under free service. There is nothing on record (case sheet) about the mode of treatment done at Karnavat Hospital by OP -1 or Dr. Patni. It is very important for the treating doctor to properly document the management of a patient under his care. Medical records form an important part of the management of a patient, to decide the issue of alleged medical negligence. The legal system relies mainly on documentary evidence, particularly, in a situation, where, medical negligence is alleged by the patient or the relatives. In an accusation of negligence, this is very often the most important evidence deciding on the sentencing or acquittal of the doctor.

For importance of medical records, we have perused an article titled "Medical records and issues in negligence" by Joseph Thomas, Indian J Urol. 2009 Jul -Sep; 25(3): 384 -388; the author mentioned that,

It is frustrating to note that inspire of knowing the significance of proper record keeping it is still in a nascent stage in India. It is wise to keep in mind that "Poor records mean poor defence, no records means no defence". Medical records consist of a variety of certification of patient''s history, medical findings, diagnostic test results, preoperative proper care, function notes, post surgical care, and daily notes of a patient''s progress and medications. An effectively acquired consent will go a long way in showing that the procedures were conducted with the concurrence of the sufferer. An effectively written operative note can secure a surgeon in case of alleged carelessness due to operative problems. It is essential that the prescribed for drugs should be readable with the name of the patient, date, and the signature of the doctor. An undated prescribed can land a doctor in trouble if the patient misuses it.

THE Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, states that every physician shall maintain the medical records pertaining to his/her indoor patients for a period of three years from the date of commencement of the treatment. If any request is made for medical records either by the patients/authorised attendant or legal authorities involved, the documents shall be issued within a period of 72 hours and refusal to do so would be misconduct. It is also important to note that, Medical Records are acceptable as useful evidence by Court as per Section 379, Indian Evidence Act 1872 amended in 1961 as it is agreed that documentation of facts during the treatment of a patient is genuine and unbiased. Medical Records that are written after the discharge or hours after death do not have any legal value. Erasing of entries is not permitted and is questionable in Court. In the event of alteration, the entire line or word should be scored and rewritten with date and time.

ON the basis of foregoing discussion and putting reliance upon several judgments, on medical negligence, we are of considered view that, there is no need for our interference, in the well reasoned order of the State Commission. It must also be borne in mind that the deceased was petitioner''s close relative, he should have shown magnanimous approach during such sad event. In spite of sympathy, he preferred this revision, and dragged the matter from the year 2007. Therefore, we impose further punitive costs of Rs. 25,000 on the OP -1, which should be paid to the complainant. The OP -1 is directed to comply the entire order, within 90 days from the receipt of this order, otherwise it will carry interest of 18% p.a. till its realisation. The revision petition is dismissed.