Vivek Jaimini And Ors. vs Metro Hospital And Ors.

P class="subparagraph">Complaint:

THE complainant, Mr. Vivek Jamini''s wife Mrs. Preeti Jaimini, since deceased, (hereinafter referred as ''patient''), a 24 years'' old pregnant woman, was under treatment and follow up with the OP 2 -Dr. Jyostna (Gynecologist) at OP -1, M/s. Apollo Hospital, Jaipur. On 29.8.2000, she was admitted in OP -1 hospital. OP -2 assured for normal delivery, and shifted the patient to the labour room. Thereafter, at 12.40 a.m. on 30.8.2000, OP 2 informed the patient about decision to conduct delivery by C -section (LSCS) to save the child and the mother. Dr. Saurabh Jain, Anesthetist, was informed by OP 2 at 1.00 a.m., who arrived at 2.20 a.m. and at 2.45 a.m., the patient gave birth to a baby girl, by C -section. The baby was handed over to the complainant. However, the patient and OT staff remained in the operation theater (OT) for quite some time. It was further alleged that when the patient was under state of coma, Dr. Jyotsna and Dr. Saurabh Jain, informed the complainant that it was due to a result of Monocef injection, which was administered to his wife, without pre sensitivity test. It was further alleged that at about 5 AM, on 30.08.2000, her condition further deteriorated. The OP -doctor advised the complainant to take her to a better hospital, where I.C.U. facilities could be provided/availed. At about 6.30 A.M., the patient was taken to Tongia Hospital, where she remained from 30.08.2000 to 11.9.2000. The patient was again re -admitted in OP''s hospital, on 11.9.2000. OP gave the assurance that they will compensate the complainant by reviving her (patient) condition. However, there was no improvement, therefore, on 20.11.2000, the complainant took her home. She remained at home, till 29.11.2000, then she was taken to Poona Hospital, Pune, where she remained under the treatment of the Neurosurgeon, Dr. Nitin Kumar Londhe, from 30.11.2000 to 8.12.2000. It was alleged that, prior to anesthesia, the patient was given a glass of water to swallow. The OP did not perform timely resuscitation in its hospital, which led to permanent damage to the brain. The OP did not give any discharge slip or medical records, while shifting the patient to Tongia Hospital. Thus, it was negligence committed by OPs; the patient remained in coma, throughout for about 4 years and died, on 21.8.2004.

THE complainant lodged FIR, but the matter was hushed up due to political influence of OP. Thereafter, alleging negligence against OPs, the complainant, Mr. Vivek Jaimini, and baby Anjali (minor) filed this complaint before this Commission and prayed for compensation, amounting to Rs. 8.5 crores under different Heads, as mentioned in the prayer clause. The complainant filed the affidavit evidence and medical records of the patient from Metro Hospital, Tongia Hospital and Pune Hospital, along with patient''s photographs taken at home, after surgery. The complainant also filed medical literature on drug ''Monocef and other medical texts to support his case. The complainant submitted Exhibits (Ex) C -1 to C -67. Defense:

THE OPs filed written version and resisted the complaint. The OPs have also filed Ext. P -1, P2 and P4. On behalf of OP 1 and 2, Dr. Jyotsana Singh filed an affidavit. She submitted that the complainant being satisfied with the efficiency of OP/Hospital, preferred his wife''s treatment. The OP -hospital has excellent OT and follows strict hygienic precaution. No one is allowed to enter into the OT, except doctor and assisting staff. After admission, patient was examined by the doctor and nursing staff. Due to foetal distress and maternal stress, the decision of LSCS was taken at 2.00 a.m. on 30.8.2000 to save the life of foetus. Accordingly, the relatives were informed. After informed consent, the LSCS was performed by OP 2. The patient was operated under spinal anesthesia because the patient was not fasting and has taken a glass of water also. After delivery of baby, injection ''Monocef was administered to the patient with pre -sensitivity test. Therefore, the doctor may not be held responsible for the anaphylactic reaction. Dr. Dinesh Sharma was called, who revived the patient immediately, however, it was decided by the OPs 2 and 3 to shift the patient to Tongia Heart Hospital at Jaipur, which is a specialised cardiac Centre with ICU facility. Dr. Surabh Jain -OP 3, accompanied the patient in the hospital ambulance. Since the patient was not discharged, but rather was only referred to Tongia Hospital, therefore, only referring note was given. There was no delay in resuscitation soon after cardiac arrest. Even the discharge ticket issued by the Tongia Hospital did not indicate that the cardiac arrest was due to ''Monocef injection allergy. The patient was readmitted to OP 1 on 11.09.2000, after discharge from Tongia Hospital. The patient was discharged from OP/Hospital on 20.11.2000.

Arguments:

WE have heard the learned counsel for the parties. The counsel for complainant submitted that, the OT staff gave a glass of water to the patient to drink, just prior to administration of anesthesia. The OP -3, at the instance of OP -1 and 2, administered Monocef injection, without conducting pre -sensitive test, during the cesarean operation. The OP 2 admitted that due to Monocef allergy, the patient immediately went in cardiac arrest. As there was no proper OT facility and no para -medical staff available, it took more time in resuscitation of the patient, which resulted in the permanent damage to the brain and patient remained in coma for about 4 years continuously and ultimately died on 21st August, 2004.

THE counsel further submitted that, the patient was shifted to Tongia Hospital, without discharge slip. The patient was admitted there from 30.8.2000 to 11.9.2000. Thereafter, on 29.11.2000, the patient was shifted to Poona hospital, Pune, till her death. The counsel further contended that, there are a number of discrepancies in the medical record; serious lapses on the part of OP/doctor, the injection ''Monocef caused cardiac arrest. The OP has not intubated the patient, in time. Therefore, there was delay in supply of oxygen to the brain. Hence, the patient suffered cerebral anoxia. Therefore, the OPs 2 and 3 are responsible for this negligence. The counsel further submitted that there was a specific order of this Commission on 26.11.2002 to provide medical records but, the OP was not bothered to provide medical records, however OP produced those records, after lapse of four years'', after discharge. The OPs are frivolously taking the ground that the cause of death was amniotic fluid embolism (AFE). The counsel for OP argued that during pre -anesthetic checkup, the patient herself gave the history of being non allergic to any drug. It was also admitted by the complainant in his cross examination. Even, during pre -MRI checkup at Poona hospital, on 30.11.2000, the complainant himself gave statement that his wife did not have any history of any allergy drug reaction. Therefore, Dr. Jyotsna was not aware of any history of any allergy drug reaction.

Findings:

WE have perused the entire medical record, maintained by OP and that of the Tongia Hospital. The surgical notes clearly mentions about the actual events that took place in the OT. The patient was properly resuscitated after the cardiac arrest. Thereafter, the patient was shifted to Tongia Hospital, the admission and treatment records shows that the patient was admitted in Tongia hospital, in emergency, patient was intubated.

AS per the drug literature, under heading "Adverse Effect of Monocef" does not show that cardiovascular arrest or shock can occur due to the administration of Monocef. Even the book by Goodman and Gilman ''The pharmacological basis of Therapeutics'' had stated ''there are no skin tests that can reliably predict, whether a patient will manifest an allergic reaction to the cephalosporins.'' On 2.8.2011, this Commission referred the case for expert opinion to Medical Board at AIIMS, New Delhi. The Medical Board of AIIMS consisting of Dr. Alka Kriplani, Professor, Deptt. of Obs. & Gynae as a Chairperson and, Dr. S. Rajeshwari, Professor, Deptt. of Anesthesiology, Dr. K.C. Goswami, Professor, Deptt. of Cardiology, Dr. Manjari Tripathi, Addl. Professor, Deptt. of Neurology as Members and Dr. Jithesh V., Department of Hospital Administration as Member Secy.

The Board opined that,

The patient Priti Jaimini (25 years) was admitted to Metro Hospital & Research Centre, Jaipur on 29.08.2000 at 10.00 P.M. as the case of labour pain

The patient was taken for emergency LSCS at 02.35 A.M. on 30.08.2000 for fetal distress and baby delivered at 02.45 A.M.

Patient developed cardiac arrest following administration of injection Monocef 1g. which was after sensitivity testing which was negative.

Patient was revived and was referred to Tongia Hospital at 5.00 A.M. on 30.08.2000.

The Medical Board is of the opinion that in the light of available documents that the treatment of Priti Jaimini was in conformity with standard medical protocol."

TO conclude, we need to look into two important questions in this case. One is "whether, the patient suffered anaphylactic reaction due to injection of Monocef or was it an Amniotic fluid embolism - Secondly, "whether, OP failed in their duty of care during patient''s Cardiac Arrest - Regarding the 1st question, as per medical literature, there are several reasons for cardiac arrest; in this case, the cause may be due to anaphylaxis or by AFE. As per medical literature (supra), the injection ''Monocef rarely causes anaphylaxis, whereas, the signs of AFE are also similar to anaphylaxis. Such occurrence is not intentional or in any body''s hands, hence OPs could not be held liable. Secondly, ''whether OP handled the Cardiac arrest (emergency) by cardiac resuscitation properly?, the clinical notes (OT notes) clearly show that, patient was intubated and oxygen saturation was maintained. Proper emergency medicines like atropine, steroids etc. were given to save the life of patient. Thus, resuscitation was done by OP, as per standards of practice. Thereafter, patient was timely referred to Tongia Hospital for further treatment. Therefore, we do not find any lapse in treatment of cardiac arrest.

THE doctors at the Tongia hospital and also at the Poona hospital opined that the condition of the patient was due to AFE. As per medical literature, this is a physiological phenomenon and may rarely occur during caesarian; due to anaphylactic reaction to fatal antigens. It will occur 1 in 80,000 pregnant women and overall mortality rate is 86 percent. Up to 50% persons of patients, die within the first half an hour of the onset of the symptoms. As per several medical literatures, Amniotic Fluid Embolism (AFE) is a potentially fatal rare obstetric complication. The sudden death or Hypoxic Encephalopathy in an apparently healthy mother, may lead to medical negligence claims by the relatives. In cases of death, a post -mortem diagnosis and histopathological examination are helpful in coming to a conclusive opinion of AFE. The counsel for OP relied upon various judgments of Hon''ble Supreme Court namely, Kusum Sharma & Ors. v. Batra Hospital & Medical Research Centre & Ors., : 2010 ACJ 1444, Jacob Mathew v. State of Punjab & Anr., : 2005 (3) CPR 70 (SC) and judgments of this Commission in case titled as Mrs. Noni Singh v. Dr. P.K. Talwar,, 2010 (1) CPR 303 (NC) and Maningegalai (Smt.) & Ors. v. Steel Authority of India Ltd., 2011 (1) CPR 66 (NC).

WE place reliance on few judgments of Hon''ble Apex Court. In the case " Martin F. D''souza v. Mohd. Ishfaq ", : 2009 CTJ 352 (Supreme Court) (CP) in which the Hon''ble Supreme Court was pleased to observe as under: - -

"41. A medical practitioner is not liable to be held negligent simply because things went wrong from mischance or misadventure or through an error of judgment in choosing one reasonable course of treatment in preference to another."

"49. when a patient dies of suffers some mishap; there is a tendency to blame the doctor for this. Things have gone wrong and, therefore, somebody must be punished for it. However, it is well known that even the best professionals what to say of the average professional, sometimes have failures. A lawyer cannot win every case in his professional career but surely he cannot be penalized for losing a case provided he appeared in it and made his submissions."

SINCE the present case is based upon an allegation of deviation from ordinary professional practice; it is worth to refer to Lord President Clyde in Scottish''s case Hunter v Hanley, 1955 SC 200, wherein it has laid down the following requirements to be established by the patient to fasten liability in case of negligence committed by a doctor: "To establish liability by a doctor where deviation from normal practice is alleged, three facts require to be established. First of all it must be proved that there is a usual and normal practice; secondly it must be proved that the defender has not adopted that practice; and thirdly (and this is of crucial importance) it must be established that the course, the doctor adopted is one which no professional man of ordinary skill would have taken if he had been acting with ordinary care. There is clearly a heavy onus on the pursuer to establish these three facts, and without all three, his case will fail."

In the case Achutrao Haribhau Khodwa and Ors. v State of Maharashtra and Ors. : (1996) 2 SCC 634, the Hon''ble Supreme Court, held that:

"in the very nature of medical profession, skills differs from doctor to doctor and more than one alternative course of treatment are available, all admissible. Negligence cannot be attributed to a doctor so long as he is performing his duties to the best of his ability and with due care and caution. Merely because the doctor chooses one course of action in preference to the other one available, he would not be liable if the course of action chosen by him was acceptable to the medical profession."

IN the instant case, the OP -3 admitted that there was anaphylactic reaction leading to cardiac arrest. Careful resuscitation was done and the patient was shifted to Tongia Hospital for further management. In our view, it was an acceptable care, taken by OPs during the emergency. Unfortunately, the patient suffered hypoxic brain injury, despite resuscitation. In the case Kusum Sharma v. Batra Hospital : (2010) 3 SCC 480 : 1 CPJ 29 (SC), Hon''ble Supreme Court laid down that, "Negligence cannot be attributed to a doctor so long as he performs his duties with a reasonable skill and competence. Merely because the doctor chooses one course of action in preference to the other one available, he would not be liable if the course of action chosen by him was acceptable to the Medical Profession."

WE have perused literature titled, Amniotic fluid embolism from Indian J. Crit Care Med., 2009 Jul -Sep; 13(3) : 129 -135, it revealed as; "Amniotic fluid embolism syndrome is an infrequent, unpredictable, and catastrophic complication of pregnancy. It is virtually impossible to predict which patients are at risk for AFE. Diagnosis must be based on a spectrum of clinical signs and symptoms and by exclusion of other causes. Most cases of AFE are associated with dismal maternal and fetal outcomes, regardless of the quality of care rendered. Amniotic fluid embolism continues to be a catastrophic illness requiring a high index of suspicion, a multidisciplinary approach and rapid resuscitation efforts in order to have a desirable clinical outcome. AFE can occur during labor, caesarean section, dilatation and evacuation or in the immediate postpartum period."

Therefore, on the basis of forgoing discussion, the expert opinion and various judgments; we do not find any negligence committed by OP doctors during the treatment of patient as such. However, in the instant case, the OP did not provide medical records to the complainant within time, even the OP produced the medical records at a belated stage, before this Commission. It has created lot of suspicion in our mind. It was an unethical act and a professional misconduct on the part of OPs. Therefore, we are constrained to impose punitive costs of Rs. 10 lakhs, which OP hospital shall pay to the complainant within 60 days; otherwise, it will carry interest @12% p.a., till its realisation.

List for the compliance report by 30th July 2015.