PRABHA SHANKAR vs NARAYANA HRUDAYALA

COMPLAINANT No. 1 is the wife and COMPLAINANT No. 2 is the minor son of the now deceased K. Shankar who was working for the Indian Railways as an Accounts Asstt. Since he had chest pain, he was admitted to Ramaiah Hospital, Bangalore on 9.7.2002 at about 8.00 Aa.m. Thereafter, he was shifted to OP 1 Hospital on the impression that OP 1 Hospital is a well known Hospital for treating heart patients. OP 2 being a heart specialist in OP 1 Hospital, examined the patient; subjected him to ECG (Echocardiogram) and thereafter advised the patient to undergo Angiogram, which was performed on him at about 6.30 p.m. on the same day. Angiogram revealed 2 blocks - one 100% and other 70%. The patient was advised to undergo Angioplasty with stenting after 4 or 5 days. The complainants contend that according to the Doctors at OP Hospital Angioplasty was preferable, when the patient was young when compared to the Coronary Bypass Surgery. It is contended that since the patient came from middle class family, he raised a sum of Rs. 2.40 lakh with much difficulty and remitted the same on 10.7.2002 as the cost of intended procedure. The procedure was tentatively scheduled for 15.7.2002. It is further contended that on 11.7.2002, OP 2 preponed the procedure to 12.7.2002 and directed the patient to come to the Hospital at about 7.00 a.m. on 12.7.2002. It is further contended that OP 2 did not elaborate the risk involved in the procedure and only informed the complainant about the positive aspect of Angioplasty. The complainants contend that she gave the consent for the procedure trusting the words of OP 2. It is further contended that OP 2 did not explain as to why the procedure was preponed from 15.7.2002 to 12.7.2002.

THE complainants contend that in the morning of 12.7.2002, the condition of the patient was stable. THE patient was taken to the O.T. at around 7.40 p.m. on 12.7.2002. About 2 hours thereafter, OP 2 informed the complainant and her relatives that the Angioplasty was not successful as the Doctors were unable to pierce the 100% block in spite of using 3 wires and thereafter informed that the patient had to go for Coronary Bypass Surgery after a week to remove the Blocks. THE complainant was told that the patient would be discharged next day. The complainant No. 1 contends that she was allowed to see the patient at about 10.00 p.m. in the Critical Care Unit and at that time he was found to be in short of breath and OP 2 was hovering asking the patient how he felt after Angioplasty.

Around 2.00 p.m. next day, Complainant No. 1 was informed to go to the Hospital during visiting hours. On going there at about 4.15 p.m., she found her husband struggling for breath and was profusely sweating in spite of having oxygen mask. The Sister incharge informed the complainant that the condition of the patient was critical. On inquiry, she came to know that OP 2 was on leave for 2 days. There was no Doctor to attend on the patient. OP 3 was not available for contacting immediately as he was said to be involved in another procedure. On contacting OP 3 at about 7.30 p.m., it was indicated to the complainant that the patient had heart attack at around 5.30 p.m. and his lungs were filled with fluid and the condition was critical. It is further contended that on further insistence on the part of complainant No. 1 and his brother, OP 3 rudely informed them that Shankar was not his case study and therefore OP 3 did not know the history of the patient and he was not in a position to comment on the future course of action. When asked why the Hospital did not inform OP 2 about the condition of the patient, OP 3 indicated that it was the duties of the patient''s relatives to inform OP 2. However, OP 3 did not give the Telephone No. or Mobile No. to contact OP 2. It is further contended that OP 3 did not attend the patient nor did he make any efforts to remove the fluid from the lungs of the patient. The complainants contend that behaviour of OP 3 was most shocking and unethical.

THE complainants further contend that their efforts to find out residential Telephone No. of OP 2 from the Front Office of the Hospital was in vain. After much persuasion, one Anilkumar gave the Mobile No. of OP 2, but the Mobile Phone was found switched off. THEreafter, a blank SMS was sent to OP 2''s Mobile Phone. Subsequently, when Ashok, the brother of complainant No. 1 succeeded in contacting OP 2, OP 2 told him that he was not informed of the condition of the patient by the Hospital. At around 10.30 p.m., Ashok contacted the Sister incharge of the Ward. Ashok was informed that OP 2 had arrived at the Hospital and was attending to the patient. Around 10.45 a.m., the complainant No. 1 and her brother were called by OP 2 to the CCU where OP 2 told that he had no idea as to why the condition of the patient deteriorated. He also told them that the fluid from the lungs would be drained and the patient would be put on ventilator. He also told them that there was 90% chance of the patient coming out of danger. He also told them that bypass surgery would be performed immediately after the patient recovered from the infection of the lungs. On 14.7.2002, when the Complainant No. 1 and her brother visited OP 1 Hospital at about 8.00 a.m., they were informed that the condition of the patient continued to be critical and his kidneys were not functioning properly. When complainant''s brother Amaranath questioned OP 2 as to why action was not taken on the previous day by OP 3, OP 2 remarked that OP 3 could have drained the fluid from the lungs and taken Chest X-Ray and sent blood sample for culture and that OP 2 had no idea as to why OP 3 had not done the same.

ON 15.7.2002 and 16.7.2002, the condition further deteriorated. In the night of 16th July, it was informed that the oxygen level in the blood was coming down gradually. In the morning on July, 2002, Dr. Jose Chaco called the relatives of the patient and informed that the condition had further deteriorated and that chance of survival was nil. At about 10.05 a.m. on the same day, the complainants were informed that the patient passed away. The complainants contend that the main difficulty arose on account of the failure on the part of OP 2 to attend to the patient for 2 days after the Angioplasty and on account of failure on the part of OP 3 to attend to the patient in the absence of OP 2. The complainants contend that sepsis must have occurred while piercing the blockage in the course of Angioplasty and the same was left unattended for the next 2 days, which has aggravated the problem, resulting in death of the patient. The complainants further contend that the death was due to negligence on the part of the OP s and the death has resulted in loss of companionship and the loss of the only earning member of the family and hence the complaint seeking compensation of Rs.19.00 lakh. Ops 1 to 3 have filed common version which was almost adopted by OP 4 being the insurer who filed separate version. Ops have contended that the patient was transferred to OP 1 Hospital from M.S. Ramaiah Hospital on 9.7.2002 with a diagnosis unstable angina. The Coronary Angiogram done on the same evening revealed that 2 vessel Coronary Artery Disease. The right Coronary Artery was completely blocked (in 100%) and the left anterior descending artery showed 70% narrowing in its mid portion. It was decided to open blocked artery and the other 70% blockage and to treat the same with medicated Cypherstent which is a state of the art device. The Ops contend that the said advice had only minor chances of repeat blockage. They further contend that the patient and his wife were explained in detail about the procedure and the risk involved. Their consent was obtained after they were fully satisfied about the treatment. They contend that Angioplasty involved 2% risk in acute Coronary Syndrome. The OP s deny that the patient who had 2 vessel blocks with unstable angina was either normal or stable. They contend that such a patient can exhibit normal and stable features when he is in the Hospital on treatment. They contend that even on such treatment, his condition can deteriorate and the best of medical intervention can prove futile. They also contend that all these risks were explained to the patient and to the 1st complainant and thereafter procedure was scheduled for 12.7.2002 based on the availability of the operation Theatre. They contend that no fixed time or duration of the procedure was conveyed to the complainants because priority had to be given to other critical patients scheduled earlier for similar procedures.

THEY contend that Angioplasty was duly performed on the patient on 12.7.2002 in between 8.45 and 9.30 p.m. by OP 2 and the senior Cardiologist Dr. Sanjay Mehrothra. It was not successful because the guide wire could not pass through the occlusion to complete the balloon dilation. THEY contend that such failure was common with most narrowing of acute coronary syndrome. Since the Doctors were unable to open all the occluded arteries, they did not try to stent the other 70% narrowing as it would lead only to partial treatment whereas with surgery both blockages can be bypassed. Hence, it was decided to wait for about a week to ward off the effect of blood thinning medication and thereafter remove blockage with an elective bypass surgery.

OPS contend that on the day of Angioplasty, the OP 2 was present in the Hospital till 11.00 p.m. The condition of the patient was stable at that time. In the mid night at about 12.30 a.m., the patient developed rigors and breathlessness and was shifted to CCU. The duty doctors Kishore and Usha immediately attended on the patient and administered medication such as injection Phenergan, injection Morphine, injection Lasix. Oxygen was also administered. From the symptoms displayed by the patient, it was presumed that he had a minor allergy commonly displayed by the patients following catheterization procedure related to the blockage in the arteries. It is contended that the patient was stable thereafter till the next evening. The relatives of the patient were requested to visit the Hospital at 4.00 p.m. on 13.7.2002 as per routine visiting hours. It is contended that in OP 1 Hospital it is department based care that being given to the patient, the needs and care of the patient are taken up by the whole department and not by any individual doctor. They contend that the condition of the patient was constantly monitored by several doctors including Dr. Sanjay Mahrothra, Dr. Bommaiah, Dr. Keshav Prabhu, etc. The patient was also monitored by the Intensivists. At about 11.00 a.m. on 13.7.2002, medication was administered to flush out fluid in the lungs and to prevent further clotting in the heart arteries in case fluid collection occurs due to blockage in the arteries. The OPS contend that since there were about 200 cardiac patients in OP Hospital, it was impossible for any individual doctor to get himself abreast of the condition of all the patients though the said Doctor might have seen the patients during his rounds. It is also contended that OP 1 Hospital runs 3 Cardiac Care Units in Bangalore to cater to the needs of critically ill cardiac patients in the city. It is further contended that on all Saturdays OP 2 is posted to the CCU at Chinmaya Mission Hospital. OPS further contend that in the absence of OP 2 in OP 1 Hospital on 13.7.2002 Dr. Sanjay Mehrothra who performed the procedure along with OP 2 and Dr. Suresh were on duty in OP 1 Hospital for the whole day and that they had seen the patient Shankar and advised requisite treatment on that day. There was also a resident doctor attending on the patient in the CCU. Ops contend that at about 4.30 p.m. on 13.7.2002, the patient developed breathing problem. OP 3 immediately examined him and found that though the pumping function of the heart was satisfactory, breathing difficulty persisted. The patient was put on CPAP mask to enhance oxygen supply. Medication was changed to lessen fluid collection in the lungs and to flush out excess fluid in the lungs as and when necessary. Blood samples were sent to Lab examination. Antibiotics were administered. OP 3 also took the opinion of Dr. Jose Charco.

They further contend that at around 8.45 or 9.00 p.m., OP 2 arrived and examined the patient; ordered for an Echo examination. It was found that the heart pumping was normal and that fluid collection in the lungs was not related to the heart. Since the sepsis was suspected, antibiotics were administered and X-ray taken. Decision to ventilate the patient was taken as the oxygen saturation did not show any improvement.

ON 14.7.2002, the patient was displaying symptoms of septic shock syndrome due to lung infection. The patient was shifted to ITU after OP 2 visited the patient. Emperic Therapy was given using various antibiotics in consultation with several intensive therapy consultants in spite of which condition did not stabilize; infection and fluid in the lungs persisted; the patient remained inadequately oxygenated despite being on ventilation. OPs contend that the complainants were constantly apprising of the patient''s condition at every stage. Ops contend that they have taken all possible care to prevent hospital infection using standard precautionary methods and applying standard infection control policies. Ops contend that septicemia in the patient could be because of his own bacterial floora by virtue of his decreased immunity and because of treatment modalities and catheterization. They contend that despite the best effort, care, supervision and treatment, the patient succumbed to septic shock and ARDS on 17.7.2002. They deny that there was any negligence on their part and deny liability to pay compensation.

IN the course of the enquiry, complainant No. 1 filed her affidavit reiterating what has been stated in the complaint and answered the interrogatories served on her. She was also subjected to cross-examination. OPs 2 and 3 filed their affidavits, answered the interrogatories served on them and also they subjected to cross-examination. One Diwakar being the Legal Asstt. of OP No. 4 INsurance Company filed Affidavit for and on behalf of OP 4. Ext Cl to C18 were marked for the complainants. The OPs have produced Ext. Rl, the records of treatment of the patient maintained at OP l Hospital. Copy of the INsurance Policy is produced at Ext. R2. We have heard the arguments for the contesting parties. Points that arise for our consideration in this case are : (1) Whether the complainants have proved negligence on the part of the OPs? (2) What relief? Point Nos. 1 and 2-The complainants have formulated specific charges against the OPs at Para-26 of the Complaint as follows: (a) Angioplasty was preponed from 15.7.2002 to 12.7.2002 without strong reason. (b) Angioplasty was performed at 7.40 p.m. instead of 9.00 a.m. scheduled on 12.7.2002. (c) The staff and the doctors in the Critical Care Ward failed to cooperate with the patient''s relatives giving Mobile Phone No. of 2nd respondent on time. (d) The 2nd respondent who conducted Angioplasty on 12.7.2002 was on leave on 13.7.2002 and 14.7.2002 and was not available to attend to the patient when complications arose. (e) The Hospital staff did not inform OP 2 about the deterioration in the condition of the patient at 1.45 a.m. on 13.7.2002. (f) OP 3 being a duty doctor neglected the patient and thereby there was a delay in identifying of sepsis and delay in removing the fluid in the lungs of the patient and taking chest X-ray, resulting in the death of the patient due to Renal failure and ARDS.

THE first two charges relate to the so called preponement or postponement of the Angioplasty. OPs have contended that the procedure was scheduled for 12.7.2002 based on the availability of the operation THEatre because priority had to be given to other critical patients scheduled earlier for similar procedure. THE complainants have not produced any evidence in particular to show as to how the so called preponement of the Angioplasty from 15.7.2002 to 12.7.2002 or the postponement of the procedure from 9.00 a.m. to 7.45 p.m. on 12.7.2002 adversely affected the condition of the patient. THErefore, we don''t find much substance in the allegations made against the OPs in this regard.

THE next 4 charges relate to the so called failure on the part of OPs 2 and 3 or other medical personnel in OP 1 Hospital to give an appropriate treatment to the patient after Angioplasty on 12.7.2002. OPs have contended that the treatment to a particular patient is given by a team of doctors and not by an individual doctor, because the Hospital functions on departmental basis and not on the basis of individual doctor. OPs have contended that the condition of the patient was constantly monitored by several Doctors including Dr. Sanjay Mehrothra, Dr. Bommaiah (OP 3) and Dr. Keshav Prabhu etc. THEy have further contended that appropriate medication was administered and steps taken to flush out fluid from the lungs and to prevent further clotting of blood in the heart arteries. THEy have further contended that OP 1 Hospital runs 3 Cardiac Care Units in Bangalore to cater to the needs of the critically ill cardiac patients and OP 2 was to attend to the patient in Chinmaya Mission Hospital on 13.7.2002 and, therefore, he was away from OP 1 Hospital that day and had returned to OP 1 Hospital in the evening and attended to the patient. OPs have produced at Ext. Rl the medical records of the patient Shankar which carries entries of the various treatments given to the patient on 13th and 14th July, 2002. OP 3 have further stated that duty Doctors Kishor and Usha have administered medicines such as injection Phenergan, injection Marphin and injection Lasix in addition to administration of oxygen. THEy have also narrated other details of treatment given to the patient which show that the patient was not left without medical attendants on 13th and 14th July, 2002. THE complainants have only produced the interested version of complainant No. 1 and not produced independent evidence much less expert evidence to show that either the OPs have failed to take appropriate steps in the matter of treatment or have failed to administer appr opriate medicines to the patient during the relevant time. It is a well known fact that in spite of the best treatment given to a particular patient, the result may go amiss. Just because the patient did not survive, the doctors cannot be found fault with. This is not a case where the principle res ipsa loquitur applied. Burden is on the complainants to produce expert evidence to show that the doctors have committed negligence in treating the patient. Evaluating the evidence as a whole, we are of the view that the complainants have failed to discharge the burden of proof. It was also contended on behalf of the complainants that after coming to know that there were two blockages in the arteries, the OPs have taken a wrong decision to go in for Angioplasty than Coronary Bypass surgery. The OPs have contended that Angioplasty is a procedure to get away with the blockage without incision to the body and such a procedure is widely preferred in the medical world than putting incision and therefore they have suggested angioplasty. This explanation given by the OPs is not rebutted by the complainants producing expert evidence. Under such circumstances, we are of the view that just because the patient ultimately expired on 17.7.2002, it cannot be concluded that the death was as a sole result of negligence on the part of the OPs. We, therefore, conclude that the complainants have failed to prove the charges made against the OPs. The complaint, therefore, fails. In the result, we pass the following Order. ORDER The complaint is dismissed. In the circumstances, the parties are directed to bear their own costs. Complaint dismissed.