P.S.KRISHNASWAMY vs APOLLO HOSPITAL ENTERPRISES LTD.

THE case of the complainant is that Mrs. Thulasi Krishnaswamy, wife of the 1st complainant was admitted in Santosh Hospital, Besant Nagar, Madras-90 on 6.6.1993, for treatment of hyperosmolar-Non ketotic diabetic acedosis. She was in the hospital for 3 days and as the treatment was inadequate, she was transferred to the opposite party-Hospital on 9.6.1993. THEreafter she was admitted to Apollo Hospital on 10.6.1993 for proper treatment. Inspite of treatment for more than 2 weeks she died in the Hospital on 25.6.1993 at the age of 72 years. THE complainants suspect that the sudden death of Mrs. Thulasi Krishnaswamy was due to wrong diagnosis and wrong treatment given to her by the opposite party-Hospital. THE complainants requested the opposite party to furnish the case sheet records relating to the aforesaid Mrs. Thulasi Krishnaswamy to ascertain whether proper diagnosis was done and proper treatment was given to her. THE opposite party by its letter dated 2.7.1993 refused to accede to the request of the complainants as the policy of the Hospital and medical record system do not permit the same. However, the opposite party has furnished Mrs. Thulasi Krishnaswamy''s death summary. After going through the same with the help of qualified doctors, the complainants were satisfied that their suspicion was well-founded. THEreafter they consulted Albert Einstein Dialysis Centre at Besant Nagar on the basis of the summary report furnished by the opposite party and other particulars. THE said Center has given a detailed report indicating the nature of the complaint the deceased was suffering from and the proper treatment which ought to have been given. THE complainants further alleged that the diagnosis done by the opposite party-Hospital was : (1) Acute renal failure, (2) Diabetes and underlying diabetic nephropathy. THE diagnosis of Acute renal failure is erroneous because of the ratio of blood urea and creatinine clearly indicates mat the deceased was in prerenal anotenia. THE blood urea could have been elevated due to gastro intestinal bleed. THE deceased must have received adequate intravenous fluids instead the patient had haemodialysis on the 2nd, 3rd, 5th, 10th, 11th day of admission which aggravated and complicated her condition. Further the haemodialysis caused her to become more dehydrated and electrolyte imbalance e.g., hypokalemia i.e., low serum potassium which were the cause of her death (dehydration & electrolyte imbalance). It was further alleged that the diagnosis diabetic nephropathy is erroneous because creatinine on admission at Santosh Hospital was 1.5 and later increased to 2.9 indicating acute component namely dehydration which thenephrologist should have checked and not first assume only Diabetic Nephropathy Swan Granz Catheter was not inserted which is simple and easy to use, which can be inserted at bed side. This Catheter will measure whether tine patient is dehydrated or over hydrated. Without proper test, the opposite party-Hospital has come to wrong conclusion. THE Neurologist opinion at the opposite party Hospital was metabolic encephalopathy, due to dehydration and electrolyte imbalance and this mental condition was made worse by administration of sodium bicarbonate which was never indicated. On tine other hand the correct diagnosis would have been hyper-osmolar-non ketotic diabetic state with dehydration. On account of haemodialysis, more dehydration was caused to the victim. THE opposite party Hospital claims to have special! section in different branches of diseases. THErefore, a proper diagnosis and better treatment ought to have been given to the deceased, for which the opposite party-Hospital charged heavily. THE opposite party-Hospital is supposed to be the best Hospital in the City having modern, up-to-date and sophisticated machines, apparatus and all other facilities. THErefore, with all these facilities and specialisation, specialists at their disposal, the opposite party-Hospital has committed a great mistake and blunder due to the negligence and carelessness by wrongly diagnosing the disease and giving treatment to her. THE complainants state further that the cardiologists diagnosis of non-Q wave myocardial infarction is wrong since the deceased''s enzyme was normal and the E.C.G. showed only non-specific changes. THErefore the team of doctors at the opposite party-Hospital were negligent in their treatment despite their rich experience and specialist knowledge arrived at a wrong diagnosis and wrong treatment to the deceased resulted in her death.

IT was alleged further that inspite of wrong treatment, the opposite party-Hospital charged heavily. The complainants suffered mental agony, anguish, tension etc. If proper diagnosis and proper treatment were given, the deceased would have lived longer. The complainants held her in high esteem, affection and fond of her. On account of the negligence and insufficiency of service the opposite party is liable to pay the following amounts to the complainant. The complainants are also entitled to the same. 1. Expenses for medical treatment Rs : 56,613/- 2. Conveyance and sundry expenses : 15,000/- 3. Damages due to negligent act and insufficiency of service for mental agony, pain and suffering loss of companionship due to the death of Thulasi Krishnaswamy :

19,00,000/- The opposite party is also liable to pay interest at 18% on the amount claimed. Under these circumstances, the complainants prayed that the opposite party may be directed to pay the above sum of Rs. 19,71,613/- together with interest at 18% per annum from the date of filing of the complaint to this date and costs of this litigation. In the version filed by the opposite party, it denied all the allegations contained in the complaint. In the version, the opposite party alleged that the deceased was brought to the Hospital at 2.45 a.m. on 10.6.1993 from Santosh Hospital Pvt. Ltd. The deceased was brought on an emergency basis in a critical condition and admitted directly to the Intensive Care Unit. The 3rd complainant gave the history that Mrs. Thulasi Krishnaswamy was suffering from diabetes Mellitus for the past 20 years and on irregular treatment with insulin injections and oral Hypo Glycemic Agents. It was also ascertained that the deceased suffered from osteo arthritis of both knees for the past 2-3 years and she was on various non-steroidal anti-inflammatory drugs. She underwent hysterectomy 20 years ago.

At the time of admission, the deceased was critically ill, drowsy and disoriented-temperature 98.4F, pulse 90/min, respiratory rate 24/min, Blood pressure 110/70 mmHg. The fundus showed diabetic retinopathy. There was bilateral pitting pedal oedema. The J.V.P. was raised. Bilateral basal crackles were heard. On admission, Random Blood Sugar was 146 mg/ dl, Blood Urea 165 mgm/dl; creatinine 1.8 mg/ dl, Na 118 mEq/L, Hb 10.2 gm/dl, TC 21,200/ cmm (Neutrophil 95%); Total bilirubin 3.1 mg/ dl. The arterial blood gas showed PO2 of 86 mmHg (on air) and compensated metabolic acidosis (PH 7.28, HCO3 13, PCO2 27.5). Trace albuminuria and 2.4 pus cells/High power field. No acetone detected. The CSF analysis biochemical and cell count was within normal limits. Blood and urine cultures were done. For the possibility of associated septicaemia, Inj. Ciprofloxacin IV 200 mg. BID started. Inj. Ranitidine IV 50mg TID and Liq. Aludrox 10 ml QID given to prevent stress ulcers. Inj. Actrapid was given subcutaneously according to the blood sugar values. A central line started to access central venous pressure showed an initial value of 18 CmH2 O. The clinical impression of the Consultant Neurologist Dr. R. Sridharan was metabolic encephalopathy with Cerebro Vascular disease. He advised Cerebro Spinal fluid analysis and correction of metabolic parameters (hyponatremia, azotamia). The Consultant Cardiologist'' opinion was ECG showed Sinus Tachycardia a non-qanterior wall myocardial infarction. He advised Nitroglycerin infusion and later Tab. Sorbitrate 10 mg. QID. The Echocardiogram showed a hypertrophied left ventricle. No regional wall notion abnormality and normal L.V. function. The Consultant Nephrologist''s opinion was that the deceased was in acute renal failure due to hyperglycaemia, hypovolaemia prior to admission, and probable diabetic nephropathy. Ophthalmic evaluation confirmed the presence of diabetic-retinopathy and maculopathy in both eyes.

ON the 2nd day, the level of consciousness was the same. The total intake and output for 24 hours was 1430 ml. and 125 ml. respectively. There was marked worsening of the renal function-blood urea-240 mg/dl; creatinine 3.0 mg/dl. Nahas risen to 138 meq/L. With the CVP level more than normal and worsening kidney functions and not Hyper Osmolar state, it was decided that the patient had gone into kidney failure and not prerenal azotaemia. The Nephrologist recommended bicarbonate, volumetric control, heparin-free haemodialysis through the femoral route. This was started after obtaining informed consent from the patient''s son Dr. P. Ramesh, the 3rd complainant herein. During dialysis, the patient was restless and mucocutaneous bleed was noted. Dialysis stopped. Assisted ventilation commenced. The ABG showed severe metabolic acidosis. The opinion of the Consultant Haematologist was taken. Platelet count was 50,000 cmm and the PT 21 sees (control 11 secs). This supported the possibility of DIC as the Fibrin Degradation Product was higher than normal and plasma fibrinogen was lower than normal. 2 Units of fresh whole blood was given. Subsequently, no bleeding occurred. After stabilization the deceased underwent bicarbonate, volumetric control hemodialysis, later. B.P. dropped during hemodialysis. There was no rise in BP. The CVP was 15 CmH2 O. Dopamine infusion given. On 12.6.1993, the temperature was 100F. The CSF and urine cultures were sterile. Serial cardiac enzymes showed decline. HBsAg and HIV antibody were negative. On 13.6.1993, there was improvement in the conscious level for the patient was alert and understood commands. BP was normal. So dopamine gradually tapered. The patient''s respiratory efforts were adequate and she was weaned off the ventilator using T, piece protocol. ABGs were satisfactory. On the advice of Consultant Diabetologist Prof. Dr. V. Seshiah, Actrapid HM infusion was given and there was a decline in blood sugar level.

HAEMODIALYSIS was done on 12.6.1993 and 14.6.1993. Dopamine stopped on 14.6.1993. Subsequently she remained haemodynamically stable. ABG done was satisfactory. Temperature 98.6F Hb was 6.5 gm/dl, 2 units of fresh whole, blood were transfused; bilirubin dropped to 2.1 mg/dl. Blood culture Sterile. There was a persistent neutrophilic leukocytosis-antibiotic continued. On 15.6.1993, subcutaneous Actrapid HM and Monotard HM injections were started. Blood sugar remained around 200 mg/dl, Between 12.6.1993 and 15.6.1993, there was gradual improvement in mental status. Urine output was 100-400 ml/day. Central venous pressure ranged between 12 and 15 CmH2 O. From 16.6.1993, urine output increased to 1000 ml and remained satisfactory for the next 3 days. HAEMODIALYSIS was done on 17.6.1993. Temperature remained normal for the next six days. On 20.6.1993 there was a fall in urine output to 300 ml. The level of consciousness deteriorated. Renal functions showed worsening. Based on the assessment, haemodialysis was done. The patient slightly improved. Next 2 days the patient was alert and conscious. The haemodynamics were stable. Decrease in systemic oedema, urine output ranged between 800-1150 ml/day. On 24.6.1993, at about 3.50 p.m. the patient developed respiratory distress. On immediate intubation, coffee ground material aspirated-suffered an episode of bradycardia. Assisted ventilation started. BP was stable. 2 hours later she suffered an episode of bradycardia followed by asystole. The patient was resuscitated. On 25.6.1993, the patient was unconscious. There was no motor response and the pupilsdilated and non-reactive. Temperature 98.4F, pulse : 90/min; BP 100/80 mmHg. The patient was on controlled ventilation. Suddenly BP dropped. Dopamine infusion started. ABG showed severe metabolic acidosis. The patient developed cardiac arrest and could not be resuscitated. The opposite party submits that the diagnosis of acute renal failure is correct for the following reasons: (i) she was oliguric for 3 days before admission; (ii) renal functions were worsening steadily; (iii) she was oedematous, CVP18 cms H2 O. This rules out dehydration and azotaemia. Giving excess I.V. fluids at this stage was contra indicated-confirmed by the specialists who examined her. There was no GI bleed and absence of melaena. So the allegation that blood urea was elevated due to gastro intestinal bleed is incorrect. The indication for dialysis were : (i) worsening renal function; (ii) acidosis; (iii) fluid overload; (iv) mental obtundation, probably due to renal failure as suspected by the Neurologist; (v) hypercatabolic state, probably due to septicaemia as opined by the physician.

The patient was evaluated by various specialists Neurologist, Cardiologist, Diabetologist, Haematologist and her management was done based on the evaluation of all the specialists. It was impossible to save her life inspite of the best efforts put in by the various specialists in view of her old age combined with multi-organ failure. Under these circumstances, the opposite parties prayed that the complaint is devoid of merits and hence has to be dismissed with costs.

WE heard both sides and perused the available records. The points for determination are : (1) Whether there was any deficiency of service or negligence in the management and treatment of the deceased Mrs. Thulasi Krishna-swamy as alleged by the complainant ?;and (2) If so, the compensation the complainants are entitled to ?

THE learned Counsel for the complainant contended that Mrs.Thulasi Krishnaswamy was admitted with normal blood sugar, blood urea and blood creatinine, Na and K. Her condition was normal at the time of admission. Proper history was not taken and history was taken from P. Ramesh who was not normal. THE opposite party did not call for medical history of the deceased from Santosh Hospital. THE opposite party did not correct dehydration and diabetic keto acidosis. THE opposite party checked only urine acetone and not serum acetone. Serum lactic acidosis was not checked. Instead of using Swan Ganz Catheter to assess the fluid status of the deceased, the CVP method used by them was not correct. Dr. K.C. Prakash negligently missed the diagnosis of dehydration. THE opposite party stated fluid intake 1430 ml output 125 ml-the intake was inadequate and that was why blood urea went up. Instead of administering 1 .V. fluids the opposite party performed dialysis on various occasions. THE deceased had prerenal failure and not kidney failure. THE learned Counsel further stated that the complainant relied on the evaluation report by Dr. Mohan R. Kamadan, MD, Medical Director, Mansfield Kidney Center, Ohio, USA. THE expert report given by Philip Dr. Bohffard, Forensic Documentary Examiner, Ohio, USA shows that the opposite party cunningly made certain entries subsequently in the Hospital records relating to the deceased to a void payment of compensation. THE complainants also relied on the report received from Albert Einstein Diagnosis Center, Madras-90. THE complainant further alleged that the deceased had cataract and how it was possible to do fundus examination as stated in the version of the opposite parry. Fresh blood was administered instead of frozen plasma to the deceased. The learned Counsel for the opposite party contended that the deceased Mrs. Thulasi Krishnaswamy was brought in a stretcher in a critical condition at 2.45 a.m. and straightaway admitted into the Intensive Care Unit. Her blood urea and creatinine were increased and she was in a semi-comotosed stage. The CVP method used to assess the fluid status of the deceased is quite in vogue and Swan Ganz method was not recommended by any of the Specialists who attended on the deceased. The deceased only had renal failure for which adequate treatment was given. She had multi organ disease and inspite of expert treatment, she succumbed to the same. There was no deficiency of service or negligence on the part of the opposite party and therefore the complaint must be dismissed.

Mrs. Thulasi Krishnaswamy was admitted in Apollo Hospital on 10.6.1993 at 2.40 a.m. accompanied by her husband Mr. Krishnaswamy, the 1st complainant and Dr. P. Ramesh, the 3rd complainant in this case. At the time of admission, Mrs. Thulasi Krishnaswamy was disoriented with slightly increased blood sugar, increased blood urea and creatinine. The complainants alleged that the opposite party inspite of being aware of that Dr. P. Ramesh suffered from Schizophrenia (as stated by the Counsel for the complainant) elicited the history from him. Dr. P. Ramesh, because his orientation was normal, he gave the history inspite of his father also present at that time. Further, the complainants did not allege that the history furnished by him was not correct. The complainants 1 and 3 must have taken the case history of Mrs. Thulasi Krishnaswamy from Santosh Hospital at the time of discharge and furnished it to the opposite party at the time of admission in their Hospital. This is the common practice followed everywhere.

MRS. Krishnaswamy''s admission straight in the Intensive Care Unit shows that her condition needed immediate care and treatment. According to the complainants, MRS. Krishnaswamy had cataract and so fundus examination as stated by the opposite party was not possible. For this, there was no evidence on the complainant''s side. The complainants alleged that the fluid status of the deceased was assessed by CVP monitoring instead of Swan Ganz Catheter which is a more accurate method to assess the fluid status. Swan Ganz Catheter is a cumbersome procedure and not used commonly in critical condition. Further, the deceased had no ventricular dysfunction to use this method. The calculated osmolality at the time of admission also rules out dehydration. Arterial blood gas showed PO2 of 86 mm of Hg. and compensated metabolic acidosis-PH 7.28; HCO3 13, PCO2 27.5.

THE deceased had renal failure for which dialysis was done, everytime with a volumetric controlled dialysis machine and CVP monitoring. THE urinary output improved to 1000 ml. on 16.6.1993. She was last dialyzed on 21.6.1993. From 21.6.1993 for 3 days, her urinary output ranged between 800-1150 ml /day. On these days, she was also conscious and could speak in between. Septicaemia was adequately treated. In an established case of diabetes, urine test for acetone to rule out Ketosis is acceptable. For suspected D.I.C. the deceased was given fresh blood transfusion. This is correct and supported by the fact that fresh blood supplies platelets which won''t be available in frozen plasma. The statements of Dr. Mohan Kamadana, MD, of Mansfield Kidney Center (Bll) and the opinion (B12) given by Albert Einstein Dialysis Center, are not acceptable because evaluation of a case must always be done in correlation with the clinical condition of the patient by her bedside. Mere date cannot be interpreted without studying the patient then and there. Further, their statements in B11 and B12 are not substantiated and proved by oral evidence. B9 and B10 records state that the original records must be examined to substantiate their opinion. So, there is no final opinion given on these records. The deceased was seen by many Specialists and all necessary care and treatment were given by the opposite parties. So, there was no deficiency of service or negligence on the part of the opposite parties. This point is in favour of the opposite parties.

POINT No. 2 : The question of compensation does not arise as there was no deficiency of service or negligence on the part of the opposite parties.

IN the result, the complaint is dismissed. Complaint dismissed.