Pushpa Devi And Ors. vs R.C. Ram And Ors.

P class="subparagraph">Complaint:

THE complaint was filed by the wife of the deceased (Dr. Rajendra Goswami), Smt. Pushpa Devi, Complainant No. -1, along with her minor children as Complainant Nos. 2 to 5, against the OPs Dr. R.C. Ram as O.P. No. 1, Dr. Anil Kumar, S/o Sh. R.C. Ram as O.P. No. 2, Dr. Ritesh, Resident Medical Officer of Ram Ratan Hospital as O.P. No. 3, M/s. POI & Poly Clinic Pvt. Ltd. as O.P. No. 4, alleging medical negligence which resulted in to the death of Dr. Rajendra Goswamy. The Facts:

Dr. Rajendra Goswami, since deceased (herein referred to as -patient) was an Ayurvedic Doctor, who, met with a car accident near Bagmara, suffered compound fracture of his right elbow. As it was a minor accident, he drove his Maruti Van back to his home. Thereafter, the deceased went to BCCL Hospital, after first aid, on 24.05.2002, he was shifted to Ram Ratan Hospital of the OP, for corrective surgery and further treatment. Professor Dr. R.C. Ram (OP -1) and Dr. Anil Kumar (OP -2) assured the patient and relatives that the hospital is fully equipped, experts will perform the operation, and hence patient will recover fully from the surgery. Also said that, need for hospitalization about 20 to 25 days. Also informed total expenses about Rs. 50 to 60,000/ -. The complainant deposited money towards treatment. On 25.5.2002, the surgery was commenced at about 11 a.m., although, it had been indicated that the surgery would take about 1 1/2 hours,, Dr. R.C. Ram performed the operation and left the hospital at around 4pm. The attendants of the patient were informed about uneventful surgery and the patient was recovering from the effects of the anesthesia in the OT. The Complainants/attendants were not allowed to meet the patient, till 05.30 p.m. As the patient did not regain consciousness, around 08.00 p.m., OP -1 made an attempt of revival of the patient and again took the patient to the OT and then at 11 pm, declared the patient dead. The OP gave the cause of death as cardio -respiratory arrest.

Therefore, the main allegation of the Complainants was that, the patient did not recover from anesthesia for about 10 hours, he was kept, without respiratory support, except oxygen pipe. The patient was hail and healthy, but the death was due to negligence of OP -2,OP -3 and other doctors at OP hospital. There was excessive dosage of anesthetic drug and improper monitoring of patient. Thus, it was negligence on the part of the surgeon and Anesthetist. The Complainant further alleged that, hospital concealed the procedural lapses which led to failure of the vital organs. During the post -operative period, the OP hospital failed to take corrective steps for recovery of the patient. As it was an OT -table death, the OP did not perform the post -mortem. It was further alleged that, the OPs did not issue the medical records. The deceased was a doctor, having good practice and was earning about 10,000/ - to Rs. 15,000/ - per month. The complainants filed this complaint under Section 21 of the Consumer Protection Act, 1986 for total compensation of Rs. 53,53,000/ - under different Headings, as per the prayer clause. In support of complaint, the complainants filed Annexures from A to F.

• The defense set by the OPs is that there was no negligence. The OP Nos. 2 and 3 are qualified doctors, with a good reputation and were having vast experience for more than 2 decades, in Orthopedic surgeries. OP submitted that, the patient suffered badly with smashed fracture of the Proximal Ulna and Distal Humerus with bandage soaked with blood on the back of right elbow region. Due to severe pain, patient was examined under short duration anesthesia, given by Anesthetist, Dr. P.K. Jaiswal. Patient had extensive lacerated wound on the back of elbow with partial skin loss, therefore, simultaneously debridement and wound toileting was done, then planned surgery was decided. The OP -1 advised all necessary pre -aesthetic investigations, and after fitness, performed the surgery."

THE OP stated that before treating the patient there was another operation concluded at 12.30 p.m. Thereafter, OP -2 and 3 operated Rajesh Goswami/the patient from 01.30pm to 03.30 p.m. The patient recovered from anesthesia and he was transferred from the OT to ICU -cum -recovery room. Thereafter, X -ray of the operated area was taken. Blood transfusion continued. The patient was attended by Dr. Jaiswal in the ICU. Therefore, due care was given, with due diligence. The OP -1 left the OT at 04.00 p.m. and thereafter, went to his office of Indian Orthopaedic Association Conference of 2002, which was located in Room No. 401, as he was the Organizing Secretary for the said conference. Dr. Ritesh Prasad, Senior Resident in the Orthopaedics was monitoring the patient. The patient was in comfortable sleep, till 10.00 p.m. At 10.30 p.m. the nursing staff noticed only 400 ml of urine, which was not increasing, although, total urinary output since morning was 1340 ml. The doctor was called immediately, he found that the patient was drowsy, BP was normal, pulse rate was high. Half ampule of Lasix IV as per the advice of Dr. Aanchal Sinha, Consultant Physician, was given. Inj. Dopamine with 5% dextrose was started. Every doctor was busy in managing the patient. The patient suddenly became breathless, oxygen inhalation was given. Inj. Sodabicard 2 amp. IV Inj. Deriphyllin 1 amp. IM was given and two vial of injection Dexona was given, but the patient developed ARDS, pulse became feeble, blood stained froth, came out from nostril and mouth followed by respiratory arrest.

THE OP doctors resuscitated the patient, and gave suction, intubation, artificial respiration, 100% oxygen inhalation, under positive pressure, with Boyle''s apparatus, but the patient went on deteriorating due to cataract arrest. Intra cardiac adrenaline was given. Cardiac massage was continued. Despite every effort, patient was declared dead, but at 11.45 p.m. Arguments and Findings:

We have heard the learned counsel for the parties. The counsel for complainant submitted that, the complications and death of patient occurred, within four walls of OT, the patient''s relatives had no access and therefore, onus is on doctor in OT, to explain the actual events that have happened. The OP doctors failed to explain the events and cause of death of the patient. The doctors intentionally avoided PM, as there was no or any consent from relatives. The OP did not inform the police. The death certificate was issued, merely on the direction of Dr. R.C. Ram, thus it amounts to negligence.

THE counsel for OPs submitted that the OP -2 is a Senior Orthopedician. The surgery went on, uneventful. Patient did not die on the OT table but died during the post -operative period, because of severe fulminating fat embolism. The patient died most likely due to fat embolism; it was a severe fatal and fulminating type of complication of musculo -skeletal trauma, which the patient suffered on 25.05.2002. The fat embolism caused Acute Respiratory Distress Syndrome(ARDS) and multi organ system failure (MOF). In this context, the OP -1 relied upon medical text books of John Crowford Adam, Watson Jones. The chapter "Outline of Fractures" including joint injuries, revealed: - - "Fat Embolism though uncommon is one of the most serious complications of fracture and despite recent improvement in management it is fatal. The essential feature is occlusion of small blood vessels by fat globules...." Again about the clinical features the book writes as follows:

"fat embolism occurs mainly after severe fractures in the lower limbs particularly, those of femur tibia. The onset is usually within two days of injury, but it is notable that there is a symptom free period between injury and onset.... An important point of distinction from cerebral contusion. The presenting feature is usually cerebral disturbance in the form of marked restlessness, confusion, drowsiness or coma,"

"the diagnosis is essentially a clinical one for there are no characteristic laboratory tests."

THE cases of fat embolism are better classified according to degree of the disease and author "Sevitt" has divided the condition into (i) Classical Syndrome, (ii) Fulminating Type, (iii) Incomplete Mild cases. The symptoms of classical syndrome, very often develop, within 24 hours of the accident, whereas about fulminating cases, the text says, as follows: - - "The patient having been conscious on admission may become Comatose within a few hours. There are some times repeated fits which can be localized or general. The collapse may occur during the early stages of resuscitation and can be the cause of death from irreversible shock. Difficulties in diagnosis may arise when there is an accompanying head injury and unfortunately the characteristic petechial rash is not always present -presumably because death supervenes before the rash can become manifest."

The Counsel further submitted that the medical records were given immediately, after a few days i.e. on 03.06.2002 to Shri D.N. Goswami, as he came to OP for some signatures on the claim forms of LIC, GIC and mediclaim of deceased. Therein also, OP -2 disclosed the cause of death as Cardio Respiratory Failure following ARDS most likely due to "Fat Embolism" on 27.06.2002 itself.

IN the context of the allegation of complainant about non -issuance of medical records, we have perused one letter dated 30.07.2001 issued by the OP -1 to the Insurance Claim Investigator regarding the indoor treatment of the patient. It is reproduced as below: "1. The patient had very badly comminuted, compound, multiple fractures of bones of elbow region of right upper limb due to high velocity injury called "Side Swipe Injuries". Except for the general weakness due to blood loss, the patient had no other physical ailment.

Cause of death was due to Cardio - Respiratory failure following Acute Respiratory Distress Syndrome also called Fat Embolism Syndrome which is the result of Road Traffic Accident leading to multiple fractures.

Yes, it was related to Road Traffic Accident.

No, police was not informed from our end, since it was not one of the type of injuries for which police information is mandatory by the treating doctors. This type of injury is a routine occurrence in the Orthopedic practice and does not require police information by the treating doctor".

THEREFORE , we are of considered view that this case of complainant is based on " suppression very, suggestio falsi ". In this context, we have perused copies of the criminal complaint filed before the Trial court, copy of the FIR and copies of the Daily case diary(Annexure A -2, A -3 and A -4). They clearly mention about the accident, how the deceased Dr. Rajendra Gosami received grievous injury around the right elbow and which was badly fractured and there was profuse bleeding and the deceased became unconscious. As the condition of the deceased has become critical, therefore, he was rushed to Patna from Dhanbad. Therefore, it is unbelievable, that after the accident the patient drove back his Maruti van to his home, for three kilometers, especially when he was not even able to sign his papers. Therefore, it is clear that complainants intentionally suppressed the critical condition of the deceased after the accident to mislead the commission. On perusal of the hospital record, we confirm that the patient suffered multiple fractures and severe injury. The clinical noting in the sheet "BHT and OT Charge" revealed that the patient was operated under GA, wound debridement done, fixation of communited intra articular distal (R) humerus done with k -wire, communited olecranon done with tension band wiring wound partly closed. A/S dressing done crepe bandage & POP stab applied.

ALSO , handwritten notes dated 25.05.2002, submitted by OP -1 shows that there was oliguria (less urine) since half an hour and shortness of breath for 15 minutes. The patient''s consciousness decreased. Therefore, it was diagnosed as ARDS. Immediately, injection Efcorlin, Sodabicarb, deriphylline and O inhalation was given. Dopamine drip was continued. Thereafter, the patient did not improve, there was cardiac respiratory arrest. Resuscitation was performed, but despite all efforts, the patient died at 11.45 p.m.

FOR legal position, what constitutes Medical Negligence, is now well established by a plethora of rulings of the Hon''ble Supreme Court of India and by several orders of this Commission. In the Bolam v. Frien Hospital Management Committee, (1957) 1 WLR 582 it was also held that a doctor is not negligent, if he is acting in accordance with standards of practice, merely because there is a body of opinion who would take a contrary view. The Hon''ble Supreme Court discussed about duty of care in cases Achyut Rao Haribhau Kodwa v. State of Maharashtra & Ors., : 1996 (2) SCC 634 and A.S. Mittal v. State of U.P., : 1989 (3) SCC 223. In Jacob Mathew v. State of Punjab & Anr., : (2005) 6 SSC 1, the Hon''ble Apex Court had concluded:

"a professional may be held liable on one of two findings: either he was not possessed of requisite skill which he professed to have possessed, or, he did not exercise reasonable competence in given case, the skill which he did possess".

THEREFORE , looking into the entirety of the case, the medical literature and the various judgments, we are of considered view that, in the instant case OP -2 and 3 are qualified and skilled doctors in Orthopedics, who had treated the patient properly, it was not negligence. They should not be blamed for the wrong happenings. The patient suffered side -sweep injury i.e. multiple fracture of bones of elbow region and it was a delicate problem of management. In such cases, the death may occur due to fat embolism leading to ARDS. Hence, it was not a medical negligence. Accordingly, we dismiss the complaint. Parties are to bear their own costs.