P.K. Sinha vs Mani Bhargava

PER MR.VINAY KUMAR, MEMBER This is a Consumer Complaint filed before this Commission in 2001. On 12.1.2004, the complainant sought permission to implead Dr. Sanjay Bhargav as an Opposite Party which was permitted. Later, by an order of 25.3.1010, the Commission decided to appoint an expert panel, for which a request was made to the All India Institute of Medical Sciences (AIIMS). The report of the expert panel dated 28.5.2010 was shared with the two parties, as per the direction of this Commission issued on 6.7.2010. The complainant is represented by his Special Power of Attorney holder, Dr. Dinbandhu Biswas. The parties have been heard on three occasions between 22.11.2010 and 23.3.2011.

THE case of the complainant Mr. P K Sinha is that his wife, Mrs. Mala Sinha was admitted to Varun Hospital, run by the OP, on 19.3.2001. THE patient was 42 years old and suffering from diabetes mellitus type II. She was admitted to the intensive care unit at 4 PM and administered 25% glucose, without making any investigation or ascertaining that she was a case of high blood sugar. In fact, two days before admission to the respondent hospital i.e. on 17.3.2001, her blood sugar had gone above 560 mg level and she was advised to take insulin injections. It is alleged that, despite this background, she was administered glucose. While being administered glucose, her condition started deteriorating and she passed into deep coma. At about 8:30 PM the OP prescribed insulin but in very low dosage. Throughout the night the patient remained in coma. The next morning at 9:30 AM she was referred to Aligarh Medical College but without the record of treatment. The patient died at about 2 PM on 20.3.2001, even before she could be taken to the medical college.

According to the complainant, the ICU of Varun Hospital, where the deceased was admitted on 19.3.2001, did not have any qualified staff or expert nor any proper equipment to deal with the serious condition of his wife. Calling it a ?glaring example of medical negligence?, the complainant has claimed compensation of Rs.22 lakhs from the OP''s. It is also alleged that, while referring the patient to the medical college, the OP refused to hand over the record of treatment and investigation reports. Later, printed reference slips only, without details of treatment given by the respondent hospital, were made available to him. This has been called deficiency in service on the part of the OP. It is also averred that on 25.4.2001, a legal notice was served on OP, Dr. Mrs. Mani Bhargav, conveying total disappointment of the complainant with the treatment his wife and seeking compensation of Rs. 22 lakhs. This legal notice has allegedly, got no response from the OP.

IN the written submission on behalf of the complainant, it is stated that the OP, Dr. Mrs. Mani Bhargav, (hereinafter referred to as OP-1) started the treatment on the basis of the history of the patient and without even getting the blood or urine samples. The patient was brought to the hospital in a conscious, and not unconscious state. The complainant points out that the OP herself mentions in her affidavit of 18.2.2010 that the patient had disclosed her condition to the deponent. This is statement in the affidavit of OP is in direct contrast with the comment in the Bed Head Ticket (BHT) that at the time of admission on 19.3.2001, the patient was in unconscious state. It is argued that the patient was given medicines orally every four hours, which could not have been possible if she had been in unconscious state. INsulin treatment was started several hours after admission of the patient. The complainant has relied upon the following two eminent authorities in support of the claim that the dosage of insulin administered was substantially below the recommended dosage? a. A Handbook On Endocrine Disorders by Dr NBJ Shah of Bombay hospital, and b. Harrison''s Principles of INternal Medicine.

It is also pointed out in the written submission that the consulting physician Dr. Ajay Mittal, a urologist, who had treated the patient soon after admission till she was referred to the medical college, has not deposed on behalf of the respondents. Instead, the affidavit of a patient and another hospital staff have been filed. Further, in the affidavit of the compounder it is stated that OP-2, Dr. Sanjay Bhargav saw the case first and started the treatment. However, the record of treatment carries initial of Dr. Ajay Mittal alone.

IN response to the above, Dr. Mrs. Mani Bhargav (OP-1) has questioned her impleadment as the respondent. According to her, she is in-charge of the Gynae unit of Varun Hospital while Dr. Sanjay Bhargav is in-charge of the general unit, as well as the proprietor of the hospital. She therefore sought her name to be deleted and substituted by that of Dr. Sanjay Bhargav. IN her affidavit Dr. Mrs. Mani Bhargav has denied having given in the treatment to the wife of the complainant and the stated that the patient was initially treated by Dr Sanjay Bhargav and later by Dr. Ajay Mittal. IN her affidavit evidence of 15.5.22002, OP-1 has categorically denied having had any thing to do with the treatment of the deceased. This is countered by the complainant in a written rejoinder. He has pointed out that OP-1 was the main doctor in Varun Hospital. Dr. Sanjay Bhargav (hereinafter referred to as OP-2), was only an anesthetist. Varun Hospital was being run by this husband & wife team. The complainant has also produced affidavit of two witnesses C.K. Biswas (nephew of the decease) and Bijay Biswas, who had accompanied him to Varun Hospital, when the deceased was taken there on19.3.2001. According to these two witnesses, the patient was initially received and administered glucose by OP-1. Op-2, Dr. Sanjay Bhargav, has filed a very detailed affidavit. His case is that he is the doctor who had treated Mrs. Mala Sinha and had therefore, sought his impleadment in the present proceedings as one of the respondents. According to him the patient was brought to the hospital "in an unconscious state where she could respond only to painful stimuli. It is unfortunate that the complainant has stated in the complaint the false facts saying that the patient was in conscious state responding to queries. The concerned doctor, as per the deponent endorsed while noting down in observations that: a. Laboured breathing, b. Response to painful stimuli only.?

According to Op-2, he was informed by the complainant that the patient was a known diabetic, on insulin. He was also informed that the patient had taken insulin on the previous night and the morning of 19.3.2001, but without taking meals. She was therefore put on 5% dextrose with 10 units of insulin and hundred ML of soda bicarb. While awaiting investigation reports relating to blood sugar and Ketonic bodies, administration of neutralised insulin was prescribed. The patient was given 10 units of insulin at 1AM, 5 at 6AM and 10 at 7 AM, intravenously. It is therefore, argued by Op-2 that the allegation that same level of treatment was continued throughout the night, is incorrect. 100ml sodabicarb was injected to counter the ketoacidosis, as indicated by laboured breathing. According to Op-2, by the time the specialist arrived, the report of blood sugar had come, indicating the level as 154. He advised blood sugar and creatinine tests, every four hours.

ON behalf of the respondents, a reference has been made to the recommendation in HARRISON?S PRINCIPLES INTERNAL MEDICINE, VOL.-II on the treatment of diabetic ketoacidosis. Treatment with low dose insulin schedules of 8-10 units per hour has been recommended. But, it also says ?Should acidosis persist unabated after several hours of treatment, larger amounts of insulin are clearly indicated.? In the absence of progressive investigation reports of blood sugar and ketonic bodies of the patient, it is not possible to say that treatment had progressed satisfactorily in this case. In fact it did not. If it had, the condition of the patient would have shown some improvement. There would have been no need for the respondents to refer her to the medical college.

IN the affidavit evidence of OP-2, reliance has been placed on a prescription of Asha Hospital, where the patient was treated earlier. On 17.3.2001, it is noted that the deceased was not taking medicines regularly and properly. He has therefore, concluded that, ?That the fact that the complainant and deceased both have been negligent and accordingly contributed to their bad luck.? The typed transcript of this prescription of Asha Hospital, cited above, is at page 13 of the Paper book.

Affidavits of two witnesses have been filed on behalf of the respondents. Praveen Kumar, Compounder says ?as per record of the hospital?, the deceased was handled by Drs Sanjay Bhargav and Ajay Mittal. The affidavit says ?Dr Mani Bhargav never attended the patients.? The other witness, Rajiv Sharma says that when deceased Mala Sinha was brought for admission OP-1 was with his wife for over an hour. She was admitted by OP-2 and she, Dr. Mrs. Mani Bhargav ?did not even come in the chamber of Dr Sanjay Bhargav for any purpose.?

IT is quite apparent that these two affidavits are filed to support the claim of OP-1 that she was not the doctor who gave the treatment. But, significantly, para 4 of the affidavit of Mr. Rajiv Sharma, carries the following disclosure? ?That on 19.3.2001, when I was waiting in the corridor of the hospital, it was approximately 4 PM when some persons along with a lady patient came. At that time the patient was not in a position to walk independently unassisted but was being supported by the persons attending on her.?

This is in direct conflict with the claim of Dr Sanjay Bhargav that the patient was brought in an unconscious state, ?could respond only to painful stimuli?. The statement of this witness is also supportive of the affidavit evidence of the two persons who had accompanied the complainant when the patient was brought to the hospital. The case of the complainant was argued before us by his PoA holder, Dr. Dinbandhu Biswas. He referred to the above mentioned prescription of Asha Hospital to show that on 17.3.2001, the blood sugar level of the patient was as high as 560mg at 11.30 AM, which was brought down to 420-450 mg at 1.30 PM, on the same day. But in the prescription of the OP, Varun Hospital, it is shown as 154 mg on arrival i.e. on 19. 3.2001. He argued that there was no blood test done to give this reading. It was put in, only to justify the fact that the patient was given glucose intravenously, continuously from 4 PM to 10 PM. The result was that the patient, who actually had a much higher level of blood sugar, went into coma. Even at 10 PM, the blood sugar level, as per OP?s own prescription, was 400 mg and the line of treatment was prescribed to bring it down to 200mg, by the next morning.

OUR attention was drawn to the recommendation in ? A HAND BOOK ON ENDOCRINE DISORDERS? by Dr. N J Shah, according to which, diabetic coma must be differentiated from insulin hypoglycemia. The handbook says, ?Diabetic pre-coma should be treated energetically by subcutaneous administration of 40 to 80 units of crystalline insulin immediately. The second dose of 30 to 50 units is repeated after three hours and later, if all is well as shown by reduction in blood sugar and disappearance of ketonuria, the patient is given 30 to 50 units of soluble insulin every 6 to 8 hours for two days. About 1000 to 1500 cubic cm of normal saline should be given by intravenous drip in the first 24 hours. Later on, fluids should be given orally. Antibiotics are given from the start to take your infection which is a common precipitating factor." The thrust of the argument of the complainant is that despite the patient having been brought with high blood sugar and in a state of diabetic pre- coma, she was not given sufficiently high doses of insulin in the first six hours, i.e. is still about 10 PM. In reply to the above, the argument of counsel for the respondent/OP''s was the after commencement of the initial medication, a specialist was called who switched the treatment over to insulin. Learned counsel for the respondents was also asked the basis for the finding of low blood sugar level of the patient on arrival on 19.3.2001 (154 mg) as it had not been tested on arrival and as it appeared to be very high (between 560 and 400 mg) when last observed in Asha Hospital, the counsel could not explain the basis. His only argument was that, going by the serious condition of the patient, the treatment had to be started without waiting for the test reports.

WE have mentioned above the expert opinion from the AIIMS had been sought. It is a very brief report, which reads as follows? ?From the records provided to us it appears that Mrs. Mala Sinha had been on a regular treatment for diabetes mellitus. On 17 March 2001 she had visited Dr Alok Gupta. As per his notes she had not taken her medication for the previous 4-5 days, her blood glucose was very high( 560mg/dl) and she had fever. Dr Gupta advised the insulin injections, antibiotics, antipyretics and modal hypoglycaemic drugs. As per the Dr''s notes at one hospital she had been having fever and vomiting. She had not taken food since the previous evening. The doctors at this hospital has treated her with intravenous dextrose and other fluids, insulin, antibiotics and anti emetics. She remained in that hospital from 4 PM 9th March 2 001 to 9:30 AM next morning. As per the information available she has been sick since 17 March 2 001 going by Dr Gupta?s (physician whom they consulted on 17th ) notes. She had very high blood glucose and evidence of infection at the time. A medical condition must have worsened and therefore they took her to another hospital two days later. By this time, the records suggest, she developed diabetic ketosis with septicaemia. Going by the documents provided it appears that there was a delay in making a correct diagnosis and initiating therapy. Therapy provided was suboptimal and inadequately monitored. The absence of detailed medical reports (clinical notes and investigation reports) limits our ability to opine further. Finally, the quality of care provided to the patient needs to also be considered in the context of available medical facilities in that region.?

WITH reference to the comment above that the medical experts were not provided detailed medical reports, clinical notes and investigation reports, a clarification was sought from the counsel of the respondents. He agreed that this refers to the reports which were expected to emanate from four hourly monitoring of the condition of the patient. The counsel however, accepted that these reports were not filed with this Commission nor made available by them to the medical experts. In the affidavit evidence of OP-2, Dr. Sanjay Bhargav, certain issues have been raised about the insurance claim relating to the deceased and why it was rejected by the life Insurance Corporation of India. Similarly, a reference has been made to the failure of Dr. D. Biswas, the PoA holder of the complainant, to repay the loan taken for running his nursing home. These issues are unrelated to the question whether there was any deficiency or negligence in the treatment of the deceased, Mala Sinha. We therefore, do not consider it necessary to go any further into them. Similarly, the claim of the respondent that no payment was made for this treatment, deserves no consideration, in view of his own admission in the affidavit that Varun Hospital is not a charitable institution for free treatment.

From the detailed discussion above, of the facts and circumstances of this case, as well as, the evidence adduced on behalf of the two parties, the following conclusions clearly emerge? a. The claim of the respondents that given the condition of the patient, treatment had to start immediately (i.e. without waiting for investigation reports) is fair and acceptable. But, the argument cannot justify continuation of the same without proper diagnosis based on investigation reports. The expert report of the All India Institute of Medical Sciences also clearly points out that there was delay in making proper diagnosis. b. Even after diagnosis, the treatment was inadequate. Medical authorities quoted by both parties show that the dosage of insulin given to the patient was significantly below the recommended levels. Understandably therefore, the AIIMS report says that the therapy provided was sub-optimal and inadequately monitored. c. The condition of the patient on arrival was much worse, according to the respondents than according to the complainant. OP-2 Dr. Sanjay Bhargav has claimed that she was unconscious when brought and responded only to painful stimuli. This makes the finding of the AIIMS that the there was delay in proper diagnosis, sub-optimal treatment and inadequate monitoring of the condition of the patient, a matter of much graver concern. d. The manner in which the record of treatment has been kept, is indicative of clear deficiency in service. Affidavit evidence led on behalf of the respondents/OPs, shows that the patient was first examined by Dr. Sanjay Bhargav and the treatment commenced. The expert, Dr. Ajay Mittal came several hours later. But the Bed Head Ticket has entries only relating to the instructions of the latter and not of Dr. Bhargav. Absence of the investigation reports, on which the treatment is supposed to be based, is indicative of very poor monitoring of the condition of the patient and needs to be viewed seriously, in the circumstances of this case. It has been categorically commented upon, in the AIIMS report. e. In the background of the affidavit evidence of OP-1 and subsequent impleadment of OP-2 as a respondent, no responsibility can be fixed directly on OP-1 in her personal capacity for any deficiency in the treatment of the deceased, but OP-1 shall be liable as proprietor of Varun Hospital where the deceased had taken treatment.

IN the light of the above conclusions, the consumer complaint is allowed. OP-2, Dr. Sanjay Bhargav and Varun Hospital are jointly directed to pay a sum of Rs.8 lakhs to the complainant as compensation for the deficiencies in the treatment of the deceased Mala Sinha, as detailed in the body of this order. The amount shall also carry interest at 6% from the date of the complaint and shall be paid within a period of three months. The period of delay, if any, shall carry interest at 9%.