PARIVAR SEVA SANSTHA vs Anil Kumar Shukla

WHEN something, as horrific as the inexplicable death of a treasured person occurs, by tossing from one private hospital to another, the story that will make the most sense is that, it could not have happened in the safe place that is in our Government Hospital. 1. This order shall decide two Revision Petitions; the facts are taken from R.P.1100/2008. The parties stand at their respective positions as referred in the complaint. On 18/10/2004, Mr. Anil Kumar Shukla, the complainant, consulted Dr. Anita Agarwal (OP -2) at Parivar Sewa Sanstha Clinic, Gwalior the OP -1, for Medical Termination of Pregnancy(MTP) of his wife Smt. Dolly, (hereinafter referred as ''''Patient ''''). It was during 16 -18 weeks pregnancy (second trimester), and the Laminera Tent was inserted by OP -2, on 18/10/2004 and patient was called on next day. The MTP started at about 11.40 am on 19.10.2004 and completed by 11.50 am, the OP -2 removed the products of conception, but, the patient started unstoppable bleeding. Therefore, at 12.40 pm. the OP -2 referred the patient to Dubey Orthopedic & Maternity Centre, where Dr. Meena Dubey (OP -3) after ultrasound study (USG) took out the retained products of conception by D & C. The bleeding did not stop, one unit of blood was given, but the condition of patient, further deteriorated, hence the patient was shifted to JR Medical College at 06.40 pm where she died at about 07.05 pm. The complainant alleging negligence and deficiency in service by the OPs, filed the complaint, before the District Consumer Disputes Redressal Forum, Gwalior. The District Forum allowed the complaint and ordered the OPs to pay total compensation of Rs.3,20,000/ - and costs Rs.1,000/ - to the complainant. It further ordered that OP -1 & 2 shall jointly pay 80% of this amount and 20% of it shall be paid by OP 3. Complainant and his four children shall be entitled to have share equally and for the share of minor children, the amount shall be deposited with any Nationalized Bank or Post Office, until they attain (21 years) Majority.

AGGRIEVED by the order of the District Forum, OPs preferred first appeals before the State Commission, which were dismissed. Therefore, against the order of the State Commission the OP 1 and 2 filed revision petition 1100/2008 and RP 1447/2008 was filed by OP -3.

WE have heard the Counsel for both the parties. The Counsel for OP submitted that, the patient Smt. Dolly was 39 years of age, had previous Pregnancies and one was caesarian section, as well as one abortion previously. She was pregnant by 18 weeks. The OP -2, after examination and pre -anesthetic check -up, inserted laminera tents on 18.10.2004. On the next day, the abortion process was started at about 11.30 a.m. and completed at 11.50 am, the products of conception were taken out, however, the patient started uncontrolled bleeding from the vagina. Hence, patient was referred to Dubey Orthopedic Maternity Hospital (OP -3) where the backup facility to OP -1 was available for the complications and emergency treatment.The OP -Dr. Meena Dubey, a Gynecologist, after USG study, performed D & C and took out the remaining products of conception. As per OP -3, on clinical examination, it was revealed as an Atonic Uterus (Non -contracting Uterus). One unit of blood was transfused. However, the bleeding continued, hence, OP -3 called Dr. Veena Agrawal, Professor of Obstetrics, who examined the patient and told to shift her to G. R. Medical College. In the meantime, the blood sample was sent to pathology laboratory for coagulation tests .The patient was shifted to GRMC at about 06:50 p.m. However, the patient died, shortly after the admission, there. The Counsel also submitted that OP -1 clinic was an approved MTP centre which had all facilities, but was not equipped for dealing with every contingency that may arise from such procedure. Hence, the OPs are not liable for medical negligence. 4. We have perused the evidence of Dr. Meena Dubey, OP -3, and entire medical record of OP -3 hospital (from the file RP 1447/2008). Relevant part of her evidence is reproduced as below; ''''When patient was brought to the hospital of OP -3, her condition was critical because of excessive bleeding. Her blood pressure was 70 and pulse was negligible. Patient had difficulty in breathing and her life was in danger. The Complainant was informed about this whole condition and was told that, the patient ''s life is in danger because of excessive bleeding and due to delay in bringing her to the hospital and there is risk of death, even after proper treatment. Then, after the consent of the Complainant, treatment was started and doctor in -charge of the maternity department of hospital OP -3, Dr. Meena Dubey, immediately admitted the patient in the intensive care room of the hospital to save her life and started the treatment. There was some improvement in patient ''s condition after giving treatment to the patient. After patient ''s examination, it was found that the uterus was relaxed, that is uterine atony. To control the continuous bleeding, the uterus was packed and sonologists Dr. Pooja Agrawal was called, who did the ultrasound. According to the ultrasound report there was some part of conceptional part from the uterus to stop the bleeding. The Complainant was informed about the above said whole condition and then Anesthetist Dr. A. K. Jain was called, who anesthetist the patient and uterus was evacuated under the ultrasound guidance. Then bleeding was stopped. There was improvement in patient ''s condition, but due to previous excessive bleeding her condition was still critical. The patient ''s husband, the Complainant, was informed about all above said facts. ''''

WHEREAS , it is interesting to note the reply submitted by Dr. Anita Agrawal(OP -1) before District Forum which is as follows: OP -3 was of the opinion that the bleeding was due to the retained products of conception and, therefore, she again carried out the procedure of termination of pregnancy under general anesthesia. The Complainant ''s wife was administered one unit of blood at the clinic of the OP -3. However, even thereafter, the bleeding could not be controlled and the blood pressure of the Complainant ''s wife continued to fall and her pulse became very feeble. Considering the serious conditions of the Complainant ''s wife, OP -3 called Dr. Veena Agarwal, a Professor at G. R. Medical College, Gwalior, who, after examination of the Complainant ''s wife, recommended that she should be immediately shifted to a Government hospital. Accordingly, the Complainant ''s wife was shifted to G. R. Medical College, Gwalior at about 06:50 p.m. However, the Complainant ''s wife died, shortly after admission in the said hospital.

FURTHER , we have perused the medical records from pages 24 to 53 available on the file of RP 1447/2008, like Parivar Seva Clinic ''s MTP intake sheet, the incident report, the case sheet of Dube Orthopedics and Maternity Hospital maintained by Dr. Meena Dubey, the USG report, and a Labour Record of Department of Obsterics G. R. Medical College, Gwalior(Annexure P -5).

AFTER our thoughtful consideration; it is an admitted fact that, patient was in 2nd trimester of pregnancy. As per the MTP intake sheet of OP -1, it is clear that the OP -2 knows that the patient was a multipara i.e. it was her 6th pregnancy and has history of previous LSCS and had got done abortion, once. The notes of OP -2 are reproduced here as under: Details of procedure: - ''''size of uterus was 16 -18 weeks, we removed the LT after giving of prostadin (1 hr. before) D& C done , completed examined of all body parts of foetus with placenta, patient shifted to the bed. ''''

It was also noted that after procedure, the PV bleeding continued (+ +), patient was treated by OP -2 with IV fluids, injection Decadron, and thereafter shifted to OP -3. The OP -3, Dr. Meena Dubey mentioned the condition of patient, on admission, as critical (as para 4 supra), the USG was performed by a qualified Radiologist, Dr. Roopa Agrawal, who reported it as ''''Bulky uterus, with lots of retained products of conception ''''. Hence, there was no complete evacuation by the procedure performed by Dr. Anita Sharma. Due to retained products, the uterus was bulky and there was continuous bleeding. We have gone through the standard books on Obstretics and Gynecology by Shaw ''s, the Williams and noted that,once the 2nd trimester MTP is decided , all investigations needed to be carried out, Blood should be arranged. Different methods of augmentations to be followed. But, in this case, after removal of laminar tents, the OP -2 performed D & C for evacuation, therefore certain complications are bound to happen like retention of products, perforation of uterus, as the fetal bone development will be there. Complete or partial perforation of the uterus is not uncommon. Risk factors, beyond the control of the doctor, include gestational age, and parity. Only the factors that are within control of the doctor, are pre -procedural cervical dilatation, type of anaesthetic, and experience.

IN this case, a woman who went in for an abortion, died as a result. Since the woman''s death, a consumer complaint was filed against OP -1 to 3 for medical and hospital negligence. The patient who was in her second trimester of pregnancy, opted to have an abortion, performed at the Parivar Seva Clinic, but, the procedure of OP -2, resulted in multiple complications which appear to be a botched abortion. As per the OP doctors 2 and 3, there was no negligence, but the continued hemorrhage lead to DIC (Disseminated Intravascular Coagulation) in the patient and resulted in death.

ON perusal of entire medical records, it revealed that, the patient was a high -risk multiparous woman, with history of previous LSCS, and abortion. The OP -2, prior to the insertion of laminera tents, has not carried USG study or basic investigations, like Bleeding time and clotting time. It was the act of omission by OP -2. After removal of Laminera Tent, she further ventured for evacuation by D & C method, which was not advisable, at all. She should have adopted augmentation to take out products of conception. She performed incomplete evacuation, which was proved by the clinical finding of OP -3 and the USG study done at OP3. The patient was critical at the time of admission to OP -3 hospital, patient was bleeding, and she should have advised the crucial laboratory investigations, to diagnose the cause of bleeding. As it was a pregnancy of 18 weeks '', there will be development of bones in the fetus; hence, there are more chances of uterine injury/perforation. We don ''t accept that the patient suffered DIC. The case sheet of OP -3, does not mention about the visit and advise given by Professor Dr. Veena Agrawal. Even otherwise, the medical record of G. M. Medical College reveals that, the patient was in hemorrhagic shock, i.e. in an unconscious state, since 3 pm and was shifted there at 6.50 pm, who died at 7.05 pm. Hence, we also find some element of negligence on the part of OP -3.

THUS , we of considered view that, the doctors (OP -2 and 3) were negligent for not adopting standard of practice to perform 2nd trimester abortion. It was an act of Omission and also Commission. Negligence is often defined as; (i) not doing something which a reasonable person would do, or

(ii) doing something which a reasonable person would not do.

Also, the medical records are not properly maintained by OPs, which show lot of discrepancies. What constitutes medical negligence? Based on the touchstone of the Bolam ''s test is well settled through a catena of decisions of the Hon ''ble Supreme Court, including in Jacob Mathew Vs. State of Punjab & Anr. (2005) 6 SCC 1, a three Judge Bench decision; Indian Medical Association Vs. V.P. Shantha and Ors. (1995) 6 SCC 651 and Kusum Sharma & Ors. Vs. Batra Hospital and Medical Research Centre & Ors. (2010) 3 SCC 480.

ALL therapeutic abortion techniques require proper training. Operators must be skilled, not only for the initiation of abortion, but also in the management of incomplete and failed procedures, uterine perforation, and such complications as haemorrhage, infection, and cervical laceration. Adequate training and ongoing experience using modern techniques with new methods will lead to a significant decrease in complication rates.However, specialized training and consistent practice are needed to perform this method, safely.

WE , therefore, for all aforesaid reasons, are not inclined to interfere with the well -reasoned order of the both the fora below. Both the revision petitions are therefore, dismissed, but no order as to costs.