Sucheta Sanyal vs Meghnad Bhowmik

THE outcome of the cataract surgery, usually is not caused by negligence or even poor practice. However, defending bad outcomes is rarely easy. In this complaint, the complainant, Smt. Sucheta Sanyal alleged negligence that the opposite party Dr. Meghnad Bhowmik (OP -1) Eye Surgeon, failed to recognize and treat endophthalmitis one day post -operatively (cataract surgery) which resulted in the enucleating of her right eye. The OP -1 maintained that the complainant was properly treated. The complainant contended that the OP, Dr. Bhowmik, had appropriately treated her on the first post -operative day, she would not have suffered the loss of her right eye. Facts of the Complaint:

The complainant, Smt. Sucheta Sanyal, aged about 65 years is a Primary School Teacher at Rangia, Assam (herein referred as "patient"). The opposite party (OP -1) Dr. Meghnad Bhowmik, an eye specialist, a resident of Calcutta used to visit and work in Alipurduar for three days a week at St. Mary''s Nursing Home opposite party -2 (OP -2). On 17.7.2001, the complainant consulted the OP -1, who, after examination, advised cataract surgery of Right eye (Exhibit CW 1/1). Further, the OP -1 expressed urgent surgery, otherwise there would be possibility of damage to the said eye. Accordingly, complainant got admitted in hospital (OP -2) and the OP -1 performed an operation at 7 p.m. on 18.7.2001, and was discharged at 9 p.m., on the same day. OP told her at the time of discharge, that there was nothing to worry, as it was a simple "Phaco surgery". As a follow up, on 19.7.2001, patient visited OP -1, who removed the eye bandage, prescribed medicines and advised rest for 1 1/2 months. Due to unbearable pain in her Right eye, on 20.7.2001, i.e. on next day, she visited OP -1 clinic at Alipurduar (Ext. CW 1/2), where Dr. Sankar was present in place of Dr. Bhowmik. He examined her and prescribed medication. He advised her to visit Calcutta and seek further treatment from the OP -1. Accordingly, on 24.7.2001, she visited OP -1 at Alokon Eye Centre, Calcutta, (entry made on CW 1/1). The OP -1, along with a team of doctors, examined her and admitted her for cleaning of eye. She was discharged on 27.7.2001, with a diagnosis of Endophthalmitis in Rt. eye (Discharge summery CW 1/3). Thereafter, OP -1 prescribed some medication, he has not disclosed her about the seriousness and real condition of her Rt. eye. Complainant returned back to her place in Assam, but her condition worsened, for which she visited OP -1 clinic at Alipurduar, on 28.7.2001, and again at Calcutta, on 4.8.2001 (CW 1/4), who prescribed only medicines, but, the OP -1 did not in form the serious condition of her Right eye. There was no improvement; therefore, she was forced to consult another Eye Surgeon at Sri Sankaradeva Nethralaya Medical Research Foundation (SNMRF), Guwahati, Assam. There, it was diagnosed as post -operative Endophthalmitis, (i.e. inflammation/infection) Schleral and Limbal necrosis (death of part) and conjunctival sloughing (shedding of skin) The prescription dated 5.9.2001 and 7.9.2001 (Ext. CW 1/5 and CW 1/6) of Sankaradeva Nethralaya and the case summary mentioned about complete damage to Right eye, and also there was Schleral and Limbal necrosis which needed surgical removal. Accordingly, she was advised for surgical removal of the eye and other risk factors to her life.

THEREAFTER , the Complainant, again visited the OP Doctor on 10.9.2001, but he turned a deaf ear to the findings of Sankaradeva Nethralaya and told the Complainant to continue the medicines, as he prescribed. With an apprehension of the foul play of Dr. Bhowmik (OP -i), and since her condition of eye was worsening, she visited Dr. Amal Deb, a Senior Consultant Ophthalmologist, Retina Specialist, IOL & Phaco Micro Surgeon at Cooch Behar, on 11.9.2001. On examination, he informed her that in Phaco -surgery, there should be no stitch in the eye, whereas, a stitch was observed in her Right eye. He further told her to remove her Rt. eye (evisceration under local anesthesia) immediately, otherwise, there was possibility of brain hemorrhage. Thus, unfortunately, her right eye was removed on 29.9.2001 at Shankar Netralaya, Chennai, its discharge summary is dated 3.10.2001. Thereafter, the Complainant returned to Rangia, Assam and noticed that pus was coming out from her mouth, eye and nose. She again, on 16.9.2001 visited the Sankaradeva Nethralaya at Guwahati, and at last visited Shankar Netralaya at Chennai on 22.9.2001, then her eye was removed on 25.9.2001 and discharged on 3.10.2001 (Discharge Summery -Ext. CW 1/9). She was advised to revisit on 8.12.2001, for glass implantation. Complainant was examined as CW 1 and it was substantiated by her husband as CW 2. She filed the medical records marked as Exhibits CW -1 to CW -9. Hence, the Complainant alleged deficiency of service on part of OP -1, for failure to diagnose and treating the serious complications. Also, alleged negligence on part of OP -1, who put the stitch for Phaco surgery, and ignored another surgeon''s findings about seriousness and failed to advise her properly, which resulted her in losing her right eye. She became visually handicapped and suffered mental agony and filed this complaint praying for Rs. 30,00,000 as total compensation.

DEFENSE of Dr. Meghnad Bhowmik (opposite party -OP -1) Dr. Bhowmik has admitted about the examination of complainant and his performing of Cataract surgery, but has denied all the allegations made by the Complainant. In the affidavit evidence of OP -1, it is submitted that on 18.7.2001, he had satisfactorily conducted operation on right eye, he did follow -up checkup on next day and found that the complainant''s right eye was satisfactory. He prescribed medicines and called her, for further checkup, after 2 weeks and issued a post -operative care and instructions card in local Bengali language. On 21.7.2001, complainant attended his clinic and was examined by Dr. S.K. Sankar, who is also an Ophthalmologist. He prescribed few medicines and informed him telephonically about the condition of patient (complainant). Thereafter, on 24.7.2001, the patient visited him at Alokon Eye Centre, Kolkata. After examination, he has suspected it, as a case of post -operative Endophthalmitis. At that time, his Ophthalmologist colleagues who were present there Dr. (Prof) Debnath Chattopadhyay, Dr. Abhrit Chatterjee, Dr. P. Pasha and Dr. Ashish Chattopadhyay also clinically examined the patient''s operated Right eye and suspected her to be a case of Endophthalmitis. After explaining the facts, on the same evening, "anterior chamber cleaning and intravitreal antibiotic and antifungal injections" were performed with assistance of other colleagues. The complainant was admitted in Alokon Eye Centre. Her condition was improved and on 27.7.2001 was discharged with necessary followup instructions. Thereafter, the OP -1 examined the patient on 4.8.2001, at Kolkata and on 28.8.2001 at Alipurduar, and found that the condition of Right eye was steady, and advised to continue medicines to avoid any deterioration. On 10.9.2001, OP -1 examined Complainant''s Right eye, and noticed deterioration. He explained her about prognosis and prescribed medicines. He further submitted that Complainant did not show the prescription dated 5.9.2001. Thereafter, the complainant did not consult him further anymore. OP -1 denied about putting a stitch in right eye during Phaco -surgery on 18.7.2001, but applied one stitch in limbus, on 24.7.2001, during cleaning of anterior chamber of operated eye, by virectomy cutter. Therefore, OP -1, in his evidence, denied that due to his negligent surgery, complainant had lost her eye. Endophthalmitis is a known complication, he has treated the patient with his fellow Ophthalmologists, with care and best of his skills. Also contended that, the other doctors (colleagues) who treated the Complainant, have not stated any negligence on his part. OP -1 acted as per standards of medical practice, hence no medical negligence; therefore he should not be liable for any claim against complainant, and the complainant failed to prove the deficiency and negligence on the part of OP -1, hence, prayed for dismissal of complaint.

IN support of OP -1''s affidavit, evidence and cross -examination of three eye surgeons namely Dr. (Prof.) D.N. Chattopadhyay, Dr. Pashupati Saha and Dr. Abhrajit Chatterjee were recorded. In their evidence, it is expressly stated that Dr. Bhowrmk (OP -1) has treated Mrs. Sanyal (complainant) as per medicalnorms and without any shortcomings. Arguments:

We have heard rival arguments of the Counsel for both the parties, who also filed their written arguments. The Counsel for the Complainant Mr. Feroze Ahmad and Mr. R.S. Sharma vehemently argued that throughout the treatment, the OP -1 was found negligent. The OP -1 failed to diagnose the complications and occurrence of Endophthalmitis during the second day of follow -up. Hence, the condition of right eye got worsened further. The OP -1 went on prescribing the same medicines, again and again, without considering the deteriorating condition of the eye of the Complainant. It was further argued that Dr. Bhowmik failed to monitor the Endophthalmitis, which resulted into pus discharge, from the nose, eyes and from the mouth of the Complainant. For this, she consulted two other Eye Specialists, who warned her of the possible danger to her life, if the eye is not removed. Therefore, in the entirety, it was due to negligence of OP -1, that she lost her right eye and suffered mental agony, for which she deserves for proper compensation, as prayed. The Counsel for complainant relied upon the case of H.S. Sharma v. Indraprastha Apollo Hospital & Anr., : II (2007) CPJ 21 (NC) in OP No. 36 of 1998.

THE Counsel for the OPs argued that the OP -1 is qualified Eye Surgeon practicing, since 1987, with high reputation. During his professional career/till now, 8,000 Cataract surgeries were performed by him. The fact that in spite of the best treatment in case of Endophthalmitis, the patient may became blind, is also well accepted in the medical sciences. He has put reliance upon the medical text. Cataract Surgery and its Complications - -Norman S. Jaffe 4th Edn: Although the incidence of intraocular infection after cataract surgery has sharply declined during the past 30 years, it is still one of the most catastrophic complications of surgery. Although newer antibiotic agents are available that combat heretofore highly resistant organisms, numerous instances of fulminating infections that defy all therapeutic efforts still occur. (Annexure F)

Clinical Ophthmology - -A Systematic Approach (3rd Edn.) - -Jack J. Kanski at Page 300.

Acute endophthalmitis is a devastating complication that occurs in about 1 in 1000 cases. Despite early treatment, about 50% of eyes become blind. (Annexure G)

COUNSEL further argued that, the issues involved in this complaint are complicated and medical negligence is a very highly technical subject which needs voluminous evidence. Hence, the Civil Court will be the proper Court and accordingly Consumer Forum has no jurisdiction. The Counsel for OP -1 relied upon the following authorities: (a) Bhupendra Nath Das v. Maharaj Ram Krishna Mission Seva Pratisthan & Ors.,, I (1998) CPJ 377.

(b) Air Commodore Satyanarayana v. L.V. Prasad Eye Institute & Anr.,, I (1998) CPJ 110.

(c) Hari Prasad Chunkai v. Mannulal Jagannath Trust Hospital & Ors., IV (2003) CPJ 15.

Discussion:

We have perused the entire medical records on file, the evidence of both the parties. The statement of complainant recorded before the Local Commissioner. On 28.1.2002, this Commission directed the complainant to submit the expert opinion or extract of some book, through which, opinion can be drawn, that the eye surgeon committed mistake in operating the eye of the Complainant.

ACCORDINGLY the Complainant filed following documents: (i) the certificate of Dr. Ashok Kumar Bhuyan (Annexure A);

(ii) an extract from "Suswathya," a Bengali magazine on health, dated 15th July, 2002 issue. There is opinion of Dr. Dalip Kumar Barman about micro surgery and Phaco surgery and its translation (Annexure B);

(iii) an extract - medical book ''Parsons'' Diseases of The Eye, Written Page 301 and 302 (Annexure C);

(iv) some reports on cataracts that the said surgery is a no -stitch, small incision procedure download (Annexure D).

WE recollect the sequence of events as, on 21.7.2001, the patient had suffered unbearable pain in her operated Right eye, i.e., on 3rd post -operative day, for which Dr. S.K. Sanakara advised medicines and further, as per his advice, she went to Calcutta, on 24.7.2001 to meet the OP -1. At Alokon Eye Care, she was diagnosed as Endophthalmitis in operated eye, and accordingly, on 24.7.2001, after AC (Anterior Chamber) was cleared with virectomy cutter, given intravitreal antibiotic and antifungal injections. She was discharged on 27.7.2001. We agree with the contentions of OP -1 that the patient, on examination, on 24.7.2001 found to have PL + PR; which should be treated with intravitreal antibiotics, as per medical science (Copy of Extract - -Annexure E). The reference will indicate that depending upon the visual capacity, the treatment should be extended. This contention was also supported by his fellow colleagues. Thereafter, patient was examined twice, by the OP -1, at Calcutta on 4.8.2001 and at Alipurduar on 28.8.2001. The important issue in this case is that the patient/complainant -1 suffered postoperative Endophthalmitis in her Right eye and, subsequently, within a span of two months, her said right eye was eviscerated. The issue is, whether, the OP -1 was negligent or not? After careful perusal of entire medical records and the sequence of events, we have given thoughtful consideration. Onperusal of brief case summery dated 5.9.2001 of Sri Sankaradeva Netralaya, Guwahati and the Case Summary of Shankar Netralaya, Chennai dated 3.10.2001, it cleared our doubts. The relevant observations on affected Right Eye are reproduced as follows:

Also, we have perused the Shankar Nethmlaya, Chennai'' Case Summery dated 3rd October, 2001, the relevant para 2 is reproduced as below:

FROM Shankar Netralaya, Chennai dated 3.10.2001. Case Summary (relevant para)

Mrs. Sucheta Sanyal (Our MRD No. 514145), a 56 -year -old lady was seen by us on 22.9.2001. She gave a history of undergoing Phaco -emulsification with intraocular lens implantation in the right eye under local anesthesia on 18.7.2001. Subsequently she was diagnosed to have post -operative endophthalmitis in the right eye and was treated for the same. She came here for further management.

On examination, her best corrected visual acuity was perception of light with accurate projection of rays in the right eye and 6/6; N18 in the left eye. Extraocular movements were full. Slit lamp examination of the right eye extensive pseudo cornea with scleral melt superiorly 4 mm from the limbus, the left eye was normal. Applanation tension was 12 m.m. of Hg. in the left eye. There was no view of the fund us in the right eye. Fundus examination of the left eye was unremarkable. Ultrasound examination of the right eye revealed multiple low reflective echoes in the vitreous cavity and was suggestive of endophthalmitis. She was advised to undergo evisceration in the right eye under general anesthesia. She was also referred to Dr. Parveen Sen, Vitreo retinal surgeon who agreed the findings and management. She underwent evisceration with scleral frill excision in the right eye on 25.9.2001. Post -operative period was uneventful. Subsequently she was reviewed here on 26.9.2001. The socket was healthy. She was advised to continue the medication and was advised to come for glass appointment on 8.12.2001.

Therefore, referring both the paras supra (12 and 13), on the basis of medical texts it is clear that there was perception of light in Right eye, hence the line of treatment adopted by OP -1 was correct. The occurrence of scleral and limbal necrosis was not due to Phacosurgery procedure, but was a sequel of Endophthalmitis after a period more than one month.

EVEN , the Ext. CW 1/8, produced by the complainant, i.e. a prescription slip issued by Dr. Amal Deb on 11.9.2001 is not supportive to her case. Dr. Deb put a diagrammatic sketch of patients operated right eye with markings of one stitch, sloughing and loss of eye integrity. We have referred to several medical texts and are of considered view that the stitch was put after proper clearing of anterior chamber, on 24.7.2001, and not during the Phacosurgery, as alleged by the complainant. It was necessary for early healing of wound. Even otherwise, according to the medical science, there is no absolute bar for applying stitches in case of Phacosurgery. After, 5.9.2001, patient met the OP -1 on 10.9.2001, but she did not disclose the doctor about the findings of Shankar Netralaya. But, on the basis of clinical examination for perception of light (PL), OP -1, further advised medical treatment, which is not negligence. We do not agree that there was delay in diagnosis and management of Endophthalmitis by Dr. Meghnad Bhowmik. OP -1 has acted as per standard of practice and we do not find any deviation. There is no act of omission or commission by the OP -1, hence no negligence. The Annexure A, the opinion of Ophthalmologist Dr. Asoka Kr. Bhuyan, has no evidentiary value, it was issued without any examination details of patient. It was issued without application of mind and any scientific basis.

BEFORE concluding, we would like to refer several decisions of Hon''ble Supreme Court and this Commission on medical negligence. The Hon''ble Supreme Court in Indian Medical Association v. V.P. Shantha, : (1995) 6 SSC 651, and Jacob Mathew v. State of Punjab & Anr., : (2005) 6 SSC 1, had concluded that - -

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.

It is worthwhile to mention here the Bolam''s case 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 standard practice merely because there is a body of opinion who would take a contrary view. Essentially three principles are applied to decide negligence of doctor.

In the instant case, OP -1 Dr. Bhowmik, is a qualified doctor, having experience and skills in his specialty, and he used his best professional judgment and due care in treatment of patient, during post -operative period.

Therefore, for the reasons stated above and on the entirety of the case, we are of the considered opinion that OP -1, Dr. Bhowmik has treated the patient, both, during pre and post -operative period, with due care and caution, as per standards of medical practice. We do not find any deficiency in the services and negligence. Accordingly, we dismiss the complaint, without any costs.