SAJJAN KUMAR CHAUDHARY vs INDRAPRASTHA APOLLO HOSPITALS

People may be aware of a multitude of facts and there may be vast amounts of information available but, if the matter is not properly understood, no knowledge will accrue, and ignorance will remain. Charles Darwin quoted that " Ignorance more frequently begets confidence than does knowledge: it is those who know little, and not those who know much, who so positively assert that this or that problem will never be solved by science.

The facts in this complaint : The complainant, Mr. Sajjan Kumar Chaudhary (Complainant No.1) and his two daughters, Ritu and Indu together, filed this complaint against the Indrapratha Apollo Hospital, Delhi and the doctors there, for the alleged medical negligence causing death of his wife Bharati after Renal Transplant (RT).The opposite parties are Indraprastha Apollo Hospital as OP-1, Chairman, Dr. Pratap Reddy as OP-2 and Medical Superintendent, as OP-3. The doctors who operated the patient were senior consultant Nephro-surgeon Dr. M. R. Rajshekhar as OP-4 and Dr. A. S. Soin, Hepato-biliary and Transplant Surgeon as OP-5. On 25.4.2000 the Patient Smt. Bharati (since deceased-referred herein as "Patient") underwent a RT at OP-1. Her sister-in-law, Smt. Vijaya Wargi, donated her kidney and the doctors at OP-1 Hospital, told that the transplantation was successful, but the patient died within three weeks after operation due to negligence of doctors at OP-1 Hospital.

The complainant alleged that without prior clinical assessment of patient, the OP performed RT. The patient''s liver enzymes were at abnormally higher side, like SGPT - 345 iu, SGOT- 238 iu and GGPT-230 iu. The patient was undergoing regular dialysis, hence it was neither an emergency nor complainant pressed for early RT. The OPs performed RT in a hurried manner, with bad intention for commercial purpose. After RT, three biopsies of transplanted kidney were taken by doctors OP4 and 5, it revealed Acute Rejection Grade-I (BANFF) with mild Acute Tubular Necrosis. On enquiry, the OP doctors told the complainant that, it was only an early rejection and nothing to worry. It was further alleged that, intra operative hypotension resulted in Oliguria (less urine), which might be due to massive blood loss. The OP doctors used excessive doses of anaesthetic agents during operation. After RT operation, high doses of steroids were administered to the patient and due to repeated biopsy which delayed the healing, resulted in perforation and gangrene of large intestine. The OP did not reveal the seriousness of patient''s condition, further the patient developed multiple perforation of large intestine (Caecum) resulting into Faecal peritonitis on 8.5.2000, but the diagnosis was made by the OP 4 and 5 on 10.5.2000, and operated upon the said patient, for the said perforations on 11.5.2000. Thereafter, patient complained of severe pain with distension of abdomen for which ultra-sonography, MRI was performed almost twice a day. The doctors unnecessarily repeated bio-chemical investigations and culture tests (2-4 times), post operatively. Subsequently, the patient died on 15.5.2000 in the hospital. The death of patient was due to negligence of the treating doctors at Indraprastha Apollo Hospital. Hence, the complainants filed this complaint for total compensation from the OP-1 hospital and doctors, under different heads, amounting to Rs.57,50,000/-. Complainant filed Discharge Summery, relevant hospital record with blood investigation, CT Scan, Renal biopsy reports. Also filed medical literature from several different medical books (Annexure A to H) and the copies of IT returns for year 1995-96 to 1999-2000 (Annexure M to Q). In support, the Complainant filed affidavit evidence of Dr. I. L. Jain, Chief Medical Controller, M. G .Hospital, Bhilwara.

The OPs resisted the complaint. The OPs submitted that, the Complainant-1 i.e. husband of the patient was very keen for an early transplant as the patient was in poor health, not tolerating dialysis very well due to hypotension. In addition, he made repeated requests for an early transplant, on the plea that the family hailed from out station and difficult for attendants to stay in Delhi for a prolonged period. On behalf of OP-1, 2 and 3, the Medical Superintendent Dr. Ritu Rawat filed written versions and affidavit. The OP-4 and 5 filed their separate written version and affidavits. OP 4 and 5 submitted that the RT operation was performed as per standard norms and there was no deficiency or negligence during entire treatment.

After RT, if non-functioning transplant graft is suspected and to rule out Acute Tubular Necrosis (ATN) in the patient, the graft biopsies at regular intervals were needed. Therefore, OP-4 performed only three biopsies at intervals, i.e. on 29.04.2000, 02.05.2000 and 08.05.2000, thus, it was not daily as alleged. Also, as per normal practice after RT, injections Solumedrol Steroid were used, in proper doses to the patient. It was necessary to treat any impending rejection of kidney and the dose of cyclosporine was lowered to improve the changes of the new kidney to work and to enable recovery of ATN. The OPs denied that due to frequent biopsies, it resulted in Trauma and Septicaemia, because such matters were beyond control and it was not negligence or deficiency in service on the part of the OPs or the treating doctors. Submissions: 1. Heard the learned counsel for the parties, at length. Arguments on behalf of Complainants: The counsel for complainants vehemently argued about the negligence of OPs. The main argument was centred on five points as:

(i) There was disturbed liver function test (LFT), which was a contra- indication for performing Renal Transplant.

(ii) The patient was hypertensive and under treatment, but the OPs took false advantage by stating that, the patient was hypotensive. Hence, there was damage to the kidney and developed tubular necrosis.

(iii) The renal biopsies were unnecessarily performed by OP doctors, caused perforation of intestine and also OPs used excessive doses of steroids.

(iv) Due to the deficiency, lack of care and the negligence, the patient developed bed sores; the patient suffered Peritonitis and Septicaemia led to death.

The counsel brought my attention to affidavit of Dr. I. L. Jain, Chief Medical Controller, M. G. Hospital, Bhilwara which was filed in support of complainant.

On the point (i) about disturbed LFT, learned counsel for the complainants, brought my attention towards liver enzymes (SGPT, SGOT & GGPT) values prior to renal transplant were on abnormally higher side. It showed increasing trend till 25.4.2000. He further argued that, the OP- 4 should have conducted the operation after bringing down the level of SGPT to normal. It amounts to negligence. Secondly, the pre-operative BP was 160/80, but the BP dropped abnormally low to 100/50 mm of Hg (Annexure 14). How such drop in BP could take place? The counsel further submitted that, the OP was trying to shift the blame on the patient, on the ground of patient''s poor health and hypotension. The patient never suffered low BP in her lifetime. In fact, the patient was suffering from hypertension since 1991 (Annexure 18) and was under the treatment of OP hospital. As the complainant had no access to the operation theatre, onus will be on the doctor to prove that there was no negligence. Hence, surgeons are vicariously liable for negligence of anesthetist.

On the third point, counsel further submitted that doctors have suppressed the findings of biopsy. The first renal biopsy was performed on 25.4.2000 which showed acute necrosis (Annexure 16). The second biopsy was on 2.5.2000 (Annexure 27). There was no urine output at all (Annexure 28). The third biopsy was performed on 8.5.2000 (Annexure 29) during which the OP doctors negligently pierced the needle through large intestine (Caecum). Hence the patient suffered pain in abdomen on 8.5.2000 at the site of biopsy. She had also fever, loose motion, which further increased with abdominal pain. Then, the patient developed tenderness, generalized gaseous distension, bowel sounds absent, these were the symptoms of peritonitis. The doctor tried to cover up the negligence by taking shelter of steroids which may rarely induce perforation in the large intestine. In this case, doctors started injection Solmedrol (steroid) on 9.5.2000, while the perforation already occurred on 8.5.2000 during the third biopsy. Therefore, there is no evidence to show that the steroids were administered in high doses, prior to the perforation.

The counsel further argued that the OP 4 and 5 failed to diagnose the perforation. They should have conducted laparotomy, if necessary but, it was delayed by two days. The TLC of the patient was reduced from 11000/cmm to only 800/-cum, hence, the patient lost the resistance to infection and the patient was subjected for removal of large part of intestine from Caecum i.e. Right Hemi-colectomy, (Annexure 42). On account of this, patient developed septicemic shock, which this led to transfusion of platelets, inotropic drugs and ventilator''s support. Thus, it was clear negligence on the part of OPs, therefore, principle of Res Ipsa Loquioter is applicable in this case. Also, the OPs did not reveal the histo-pathological report of Hemicolectomy and the doctors decided to perform second laparotomy operation, within 42 hours, which was unwarranted, the operative wound was not properly stiched. The last point argued was that the OP 4 and 5 did not take informed consent, but took signatures on blank forms, thus it was not a valid consent. Hence, the OPs were totally negligent to treat the patient. Arguments on behalf of Opposite Parties:

The learned counsel for OPs 1 to 3 argued that the complainant chose to admit his wife at Apollo Hospital, on his own volition and choice. The patients who seek transplant are those who suffer badly from the consequences of kidney failure and intolerance to dialysis. Due to hepatic congestion, there was chronic fluid overload as the cause of elevated liver enzymes. In fact, the Nephrologists (kidney physician) had certified the patient and the donor for renal transplant. Thus, it was not contra-indication for kidney transplant. Further submitted that, Dr. Madhok, an experienced Anaesthetist took all safety precautions during patient''s transplant surgery, like administrating of IV fluid therapy, one unit of packed red cells and medications such as Dopamine to augment the blood pressure. The BP remained low due to poor health and bodily limitations of patient. Hence, it was not negligence on the part of the treating team of doctors. There was no blood loss, only one unit of blood was needed.

The last graft biopsy was performed by Nephrologist, under ultrasound guidance (Ex. OP 1/A), on 8.5.2000, which was reported as ''improved ATN and mild acute rejection''. She had low grade fever and loose stools and received treatment for gut infection and was advised increased oral fluids by the nephrologists in view of fluid loss in stools. Patient was stable and underwent 4 hour hemo-dialysis, by maintaining her vitals intact.

The counsel submitted that on the late evening of 10.05.2000 , OP-5 made a clinical suspicion of peritonitis, thus after adequate preparation and Anaesthetic evaluation, the patient was taken up for an emergency exploratory laparotomy on the late night of 10.05.2000. It was noted that, there was discoloration of a large area of the gut, which was due to an ischaemia of the gut resulting from immunosuppression. If the perforations were caused by biopsy needle by any stretch of imagination it would not have caused such diffuse discolouration of the gut. Further submitted that ,it is a known and accepted fact all over the world that unfortunately not all patients survive after kidney transplantation After all efforts, the OP hospital could not save the life of the patient, it does not amount to any negligence or deficiency in service on the part of the OP consultants. Findings and Discussion.

I have perused the medical records as well as, surgical and clinical notes. Regarding consent, the complainant signed the consent form with his open eyes, he cannot take frivolous ground that, and he signed some blank papers. The renal transplant is one of the major planned surgery, it needs proper planning, counselling, donor selection, number of investigations. Thus, the complainants'' submissions are bereft of merit. Perused the affidavit filed by Dr. I. L. Jain, in my opinion, it is also not supportive to the view of complainant.

It is clear that, after the last biopsy taken on 08.05.2000, the patient complained of pain in the operated area of biopsy, also some pain in abdomen and she developed diarrhoea and fever on 09.05.2000 and 10.05.2000. The OP-5 suspected peritonitis on 10.05.2000 for which laparotomy was decided. Accordingly, an emergency laparotomy was performed, the perforation was repaired and the faecal peritonitis was cleared. Even though the collection is possible due to peritonitis which is beyond control of OPs, it cannot be held to be negligence or deficiency in service on the part of OPs. Again, on 13.05.2003, on the basis of this clinical diagnosis and to save the patient''s life, another laparotomy was carried out and another to clean abdomen, which is also not negligence. The OP gave Plasmapahresis which was necessary for treating the kidney rejection and also to clear the toxins from the blood. After perusal of Operation record, I don''t agree that there was any delay in performing RT. The record shows that the donor surgery (including anaesthesia) was started at 1 p.m. and finished at 6 p.m. (An. 1). The recipient surgery was started at 6.15 p.m. (An. 2) and the kidney was transplanted, soon afterwards. Hence, there was no delay in transplanting the kidney.

The medical literature explains that Transplantation is a complex process. The functioning of the kidney after RT, is dependent on several factors, including Immunological incompatibility of the donor kidney. ATN is known for remission, though, the recovery period could take, as long as three months'', in some cases. Use of steroids is well documented, the OP advised Injection Salmodrol (steroid) from the day of operation, the dosage was 500mg. It was not an excess dose. Steroids will be helpful to treat any impending rejection, and also useful when the recommended doses of cyclosporine is lowered to enable ATN to recover. The medical literature show that the tubular epithelium of the kidney has a tremendous ability to regenerate and may result in restoration of full function of the kidney. The OPs took renal biopsies in intervals as per protocol under ultrasound guidance. There are remote chances of injuring large intestine or caecum. Even if it is presumed that perforation had occurred due to biopsy , in such a case, there should be a single puncture, but in this case, operative findings clearly mention that there were multiple perforations. Thus, it''s impossible that, a single needle biopsy (last biopsy) will create such perforations. Therefore, I disagree that there was any negligence by OP doctors, while performing renal transplant and post-transplant biopsies.

In the case of Kusum Sharma vs Batra Hospital Hon''ble Apex Court observed that, the normal human tendency is to pick fault whenever there is a death in the family for which the doctor cannot be made a scapegoat. It is a matter of common knowledge that after some unfortunate event, there is a marked tendency to look for a human factor to blame for an untoward event, a tendency which is closely linked with the desire to punish. Things have gone wrong and, therefore, somebody must be found to answer for it. Finding such CPA complaints against doctors on the rise and in many cases these being frivolous, the Bench said, "Courts have to be extremely careful to ensure that unnecessarily, professionals are not harassed and (or else) they will not be able to carry out their professional duties without fear." Medical Negligence has been discussed in several judgments of Hon''ble Supreme Court and this commission. The Hon''ble Supreme Court held in C. P. Sreekumar (Dr.) vs. S. Ramanujam, (2009) 7 SCC 130, case as follows:-

the onus to prove medical negligence lies largely on the claimant and that this onus can be discharged by leading cogent evidence. A mere averment in a complaint which is denied by the other side can, by no stretch of imagination be said to be proved. It is the obligation of Complainant "to provide the facta probanda as well as the facta probantia" Therefore, on the basis of foregoing discussion, it is clear that, the OPs performed renal transplant as per standard of medical practice, there was no deviation of practice or excess dosage(s) of steroids. In my opinion, the unfortunate death of patient was due to known complications of use of steroids, which cannot be equated to medical negligence. The doctors who performed transplant surgery are well qualified, having vast professional experience in their speciality. Even the hospital infrastructure did not show any deficiency. Therefore, the complaint is dismissed. No order as to costs.