DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi- 110016

Case No.77/2020

Nirupama Dutta

45 C MIG Flats, Sheikh Sarai, Ph-I

New Delhi-110017.                                                      .…Complainant

                                                 VERSUS

Max Smart Super Speciality Hospital

Through Its Medical Superintendent

Max Smart Super Speciality Hospital

Saket, New Delhi.                                                         ….Opposite Party

Coram:

Ms. Monika A Srivastava, President

Ms. Kiran Kaushal, Member

Present:    Complainant in person.

Present:    Adv. Sujata Rao Ayde along with Adv. Sachidanand Roy for OP.

ORDER

Date of Institution:13.03.2020

Date of Order       :16.07.2024

President: Ms. Monika A Srivastava

Complainant has filed the present complaint seeking compensation of Rs.19,50,000/- for the mental agony and harassment undergone and Rs.50,000/- as cost of litigation.

1. It is stated by the complainant that her mother was unwell since 23.07.2018 and was taken to a physician, some tests were prescribed, and she was advised to review with the report.  Prescription dated 31.07.2018 is annexed as annexure C-1.

2. It is stated on 01.08.2018 she was advised by the same doctor for a second opinion, and she was referred to Dr. Rajiv Aggarwal, Max Smart Super Specialty Hospital, Saket where she was admitted in HDU with a BP of 160/90mg.  Prescription dated 01.08.2018 is annexure C-2.

3. It is further stated that she was kept in the OP hospital for five days and discharged on 05.08.2018 with a diagnosis of Type-II DM, Systemic Hypertension, no RWMA, LVEF 60%, GR-I Diastolic Dysfunction and mild PAH.  Routine investigations were conducted including scan of spine and brain which revealed age related changes.

4. The mother of the complainant was discharged in a stable condition on 05.08.2018 case sheet of admission is annexed as annexure C-3 and the bill was Rs.1,22,645/- besides expenses incurred on pre and post hospitalization period.

5. It is stated that on 31.10.2018 she felt unwell again and was taken to OP hospital with symptoms of “ghabrahat’ and sweating associated with shortness of breath.  Her ECG showed ‘St elevation in inferolateral leads’. She was again admitted on the same day and a coronary angiography was done on 31.08.2018 which revealed “recanalised LAD, Type-III with 40% - 50% plague”. She was discharged on 02.11.2018 in a stable condition with a hospital bill of Rs.60,285.30/- on 16.11.2018 she was again taken to the OP hospital with complaint of “giddiness since 1 day” with the  parameters as BP 120/80, SPO2  99% on room air, CNS – no focal neurological defect, Afebrile, CVS-S1S2 (+)”.

6. A repeat angiography was done within fifteen days of the first angiography on 89 years 7 months old lady within 15 days of the earlier angiography.  It is stated that aggressive and invasive treatment was administered which reduced her to a vegetative state and eventually led to her death on 02.12.2018.  It is stated that 4-5 blood tests were done daily and when the hemoglobin levels fell OP insisted on given her a blood transfusion. 

7. It is further stated on 21.11.2018 she was found unconscious lying in her own faeces in the ICU with no one to attend her. After speaking to the primary doctor she was finally shifted to a bed in front of the nursing station.  It is stated that on 23.11.2018 OP gave a form for ventilator support and asked the family to sign however, the case sheet of 23.11.2018 mentioned the condition of the patient as “improved”.  As per the case sheet the advice was to “stop antibiotics as there is no evidence of any active infection”.

8. It is further stated that the mother of the complainant was being experimented with.  Her arms were covered with needle marks and kept bandaged, she was kept sedated and only when she was brought home her bandages were removed the needle marks were visible.

9. It is further stated that on 23.11.2018 the family was called to give their concurrence for pleural fluid aspiration and was informed on 24.11.2018 that only 10 ml of the fluid was taken out since the bent spine of the complainant required ultrasound guided aspiration. The complainant seeks to know from the OP why the pleural fluid was undetected till it reached an emergency and that the old lady subjected to so many procedures in a callous manner. 

10. It is further stated that blood sugar tests were built for as many three times a day but not a single blood sugar report was provided.  It is stated that though the OP had been informed about the decision of the complainant to leave on 25.11.2018 yet OP did a series of blood tests on 26.11.2018 when the complainant’s mother was reduced to a vegetative state and the complainant had decided to take her home against medical advice.

11. It is the case of the complainant that the case sheet and the billed amount do not tally.  It is also stated that the medication sheet reveal gross over-medication and at times contra-medication.  It is stated that OP has indulged in unfair trade practices by conducting blood test 3-4 times a day instead of one.  It is stated that 32 tests for sugar were done in 11 days.  It is further stated that reports were never provided. It is also stated that the billing medicines were not prescribed in the case sheet.  It is also stated that as many as three ECGs were done in a day.

12. It is stated that complainant has suffered on account of these acts of the OP which amount to gross deficiency in service, unfair trade practice and malpractice.

13. OP in its reply has stated that the complaint is based on baseless, unfounded, fallacious, reckless, erroneous understanding of medical science.  It is stated that no specific, scientific and justified allegations have been made by the complainant against the hospital with regard to negligence or deficiency in providing services or unfair trade practices.

14. OP has stated that the mother of the complainant was 89 year old lady who was treated at the OP hospital on three occasions.  In the first hospitalization in August, 2018 patient was admitted as a referred patient for ruling out any cardiac cause including unstable angina for which cardiac enzymes, ECG and Echo were done. Since the complainant was complaining of imbalance, heaviness of head and burning sensation in B/L soles, NCCT head and CT spine screening was advised which revealed age related changes and scoliosis.  She was discharged on 05.08.2018 in a clinically stable condition after her giddiness improved and holter report was awaited.  Subsequently, Holter test confirmed Sick Sinus Syndrome with minimum HR 44 bpm for which medical follow up was advised with aspirin and anti hypertensive drugs.  She was told to review after seven days in Cardiology OPD.

15. In her second hospitalization, the patient was admitted with suspected ST Elevation MI for which emergency coronary angiography was done and which revealed “recanalised LAD”.  On 02.11.2018 patient was discharged in a clinically stable condition with discharge medication advice to review in Cardiology OPD after seven days but no follow up was done.

16. In her third hospitalization patient was brought to hospital emergency where her ECG showed fresh ST Elevation in antero-lateral leads and TROP-I was raised.  Patient had runs of ventricular tachycardia, for which she was given amiodarone bolus dose followed by infusion.  Diagnosis of fresh acute MI with ventricular tachycardia was made, for which the best course of action appeared to be immediate high risk coronary angiography and revascularization along with concomitant medical management. After taking consent from the patient’s attendant emergency coronary angiography was done on 16.11.2018 which revealed insignificant coronary artery disease. 

17. On 22.11.2018 when the patient had high TLC of 18100, X-ray chest was repeated, which showed large pleural effusion with breathlessness.  Therefore, Pulmonology team was consulted who advised to drain it. It is submitted that on 23.11.2018, Internal Medicine team doctor, in his CPRS Note of around 01.35 PM, suggested to stop antibiotics.  Subsequently, pleural fluid was aspirated from the patient’s chest, which was duly recorded by the respiratory medicine team doctor in his CPRS Note of around 04.48 PM.

18. On 24.11.2018 at around 11:38, respiratory team doctor documented the findings from pleural fluid.  At around 12:44 PM (i.e. almost an hour later), the patient was seen by Clinical Cardiology team doctor who also reviewed the findings from pleural fluid.  Pleural fluid was suggestive of Exudative Etiology, which generally denotes infection.  In view of aforesaid subsequent findings, the Clinical Cardiology team doctor advised to continue antibiotics and wait for culture report, which findings were not present when Internal Medicine team doctor suggested stopping of the antibiotics.  Moreover, the patient would have needed antibiotics as cover for the needle aspiration of pleura on 23.11.2018 as well as the subsequent repeat procedure that was done on 25.11.2018.  Copy of above referred CPRS Notes dated 23.11.2018 of 1.35PM and 04:48 PM and 24.11.2018 of 11:38 AM and 12:44 PM are already on record and marked as Exb.OP/4 (colly).

19. It is further stated by the OP that the attendants of the patient were kept informed about the diagnosis, prognosis and attendants of the patient were duly counseled and their consent was sought in fixing the line of treatment.  In view of the fact that the patient was an elderly patient was on antiplatelet drugs for suspected acute coronary event and low molecular weight, heparin for stroke prevention in atrial fibrillation and was deemed to be at high bleeding risk, choice between one time needle aspiration or chest tube (ICD) insertion (more effective but with higher bleeding risk) was duly discussed with the attendants.  It is submitted that pleural aspiration was attempted by the Pulmonology team on 23.11.2018 but only about 10ml. diagnostic pleural fluid was aspirated as the patient became too irritable and uncooperative.  Therefore, the procedure was abandoned as a means of abundant precaution as continuation of the procedure could have become too risky of injuring the patient internally and an ultrasound (USG) guided therapeutic tapping was advised.  A pigtail insertion was done by Interventional Radiologist under USG guidance after taking an informed consent to relieve the pleural effusion and dyspnea on 24.11.2018 after giving 2 units packed cells and omitting clopidogrel, 500 ml of pleural fluid was drained.  The patient was again seen by the pulmonology team doctor on 24.11.2018 and pigtail removal was advised.

20. Since the patient was critically ill and therefore, regular bed side blood sugar monitoring was required.  To capture the findings of blood sugar, no separate report is generated and the same is mentioned in CPRS Notes, as done in the case of the patient also. It is submitted that the necessary and required blood tests were done to monitor patient’s renal function, infection status and coagulation profile. It is further stated that blood sugar was monitored by glucometer 3 times a day because patient had altered sensorium with suspected sepsis and being on nasogastric feeds, the patient had risk of both hyper and hypoglycemia and need effective glycemic monitoring and control was needed. For patients developing renal impairment and reduced urine output, it was even more essential to record blood sugar for early detection of hypoglycemia.  Recorded blood sugar of the patient showed significant variation and therefore, was regularly monitored in this critically ill patient. 

OP has placed reliance on medical literature titled as “Hyperglycemia” in critically ill patients: Management and Prognosis by Amina Godinjak, Amer Iglica, Azra Burekovic, Selma Jusufovic, Anes Ajanovic, Ira Tancica and Adis Kukuljac” Med. Arh. 2015 June 169 (3). It is further submitted that blood sugar was monitored by glucometer 3 times a day because patient had altered sensorium with suspected sepsis and being on nasogastric feeds, the patient had risk of both hyper and hypoglycemia and needed effective monitoring and control, if needed. For patients developing renal impairment and reduced urine output, it was even more essential to record blood sugar for early detection of hypoglycemia.  Recorded blood sugar of the patient showed significant variation and therefore, was regularly monitored in this critically ill patient.

21. It is further submitted that in critically ill patients, hyperglycemia (High Blood Sugar level) is common and associated with adverse outcomes.  Several studies showed that both hypoglycemia (Lower sugar level lower than the standard range) and severe hyperglycemia increase in hospital mortality.  In particular they draw a J-curve relationship between blood glucose concentration and mortality. Reliance is placed on medical literature by Balloni, A. Lari, F. and Giostra, F. (2017) and Acta Bio Medica Atenei Parmensis 2017, “Evaluation and treatment of hyperglycemia in critically in patient”, Acta Bio Medica Atenei Parmensis 2017, 87(3), pp.329-333.

22. The allegation of the complainant that regular blood test caused blood loss adversely affected on the health/Hemoglobin count of the patient, is based upon wrongful and misconceived presumptions and conjectures. It is submitted that at the time of the patient’s admission on 16.11.2018, her hemoglobin was 9.3 and on 21.11.2018, her hemoglobin was 9.5.  Her hemoglobin continued to be more than 8g/dl until 24.11.2019 when blood transfusion was needed only after pleural tap was done. The pleural tap was necessary to make a diagnosis. Stool for occult blood was negative on 25.11.2018 and no other obvious source of bleed was identified.
23. With respect to drawing out blood once and doing all the tests, it is submitted that a patient is managed according to his/her progressing clinical condition.  To decide right management for a patient, it is necessary to know his exact clinical condition, for which necessary tests/investigations are required to be done.  If the blood is drawn out once for all future tests/investigations, it will show the clinical condition of the patient of the time blood was drawn out and a doctor will not come to know about effect of treatment given to the patient subsequently and will not be able to make decision for future management of the patient.
24. Repeated ECG was required in view of suspected myocardial infarction and subsequent ventricular tachycardia.  The patient remained in ICU throughout with continuing instability and worsening.  Hence ECG was necessary to document the rhythm and also look for signs of ischemia (decreased coronary blood flow) and electrolyte disturbance.  It is submitted that necessary tests were carried out to monitor clinical progress of the patient and to decide appropriate course of treatment.
25. Anti Parkinson’s medications were withheld in view of significant cardiovascular side effects of Syndopa plus and its metabolite (Dopamine) as it can induce orthostatic hypotention/arrhythmias (both atrial and ventricular).  Further, it can also cause drowsiness as a side effect. At the time of admission on 16.11.2018, the patient was already drowsy.  As the patient was having cardiovascular abnormalities in the form of arrhythmias and sick sinus syndrome, it was a justified step to withhold anti Parkinson’s medication at the time of admission, in order to reduce the chances of above-mentioned cardiac abnormalities, which were the primary disease at that point in time. It is stated that stopping of these medicines for short duration will not have any major side effect. The medication was reintroduced for ruling out the drug side effect.

• Reliance is placed on the following medical literatures in support of its aforesaid arguments, which are already on record:-

1. Salawu F. Olokoba A. Excessive daytimre sleepiness and unintended sleep Episodes Associated with Parkinson’s Disease. Oman Medical Journal 2015; 30(1):3-10.
2. Noack C. Schroeder C., Heusser K, Lipp A. Cardiovascular effects of levodopa in Parkinson’s disease. Parkinsonism Relat Disord. 2014 Aug;20(8):815-8. doi: 10.1016/j.parkreldis.2014.04.007. Epub 2014 Apr 30. PMID:2481939.

26.  It is denied by the OP that course of treatment adopted by the doctors reduced the patient to a vegetative state and led to her death on 02.12.2018.  It is stated that patient was given appropriate treatment as per the standard medical protocol and her prevailing clinical condition.   It is further denied by the OP that the mother of the complainant i.e. the patient was being experimented with.  It is stated that the patient was being treated by a team of experienced doctors.  It is stated patient being an elderly patient had very fragile veins.  After three admissions with ICU stay each time, the patient had multiple venous needling and difficult access. 

27. In her rejoinder, complainant has mostly denied the allegations made by the OP in their reply.  It is stated that tests conducted on the patient i.e. the mother of the complainant were unrelated to the presenting symptoms such as brain scan and spine scan thereby adding to the cost of the treatment. It is also denied that the patient was treated as per the established medical protocol and with the prevailing clinical condition of the patient.  It is further denied by the complainant that OP was diligent and active in treatment of the patient.

28. It is reiterated that the patient being 89 years 7 months old should have been managed conservatively instead of the OP resorting to aggressive and invasive treatment. It is stated that OP has in its reply admitted that the patient had ‘thrombophlebitis on both arms’ which was a consequence of repeated blood tests several times a day.

29. It is further stated that OP had admitted that the general condition of the patient had improved but no cogent reason was given to put the patient on ventilator support.  It is stated that Parkinson’s medicine was stopped for five days which led to further neurological damage.  Complainant has also questioned the evidence whether blood sugar tests were really done on the patient as there was not a single report of it.

30. It is stated that OP has given invasive treatment to an elderly patient within 15 days of hospitalization when both the times the angiography report showed ‘Insignificant CAD’. It is stated that complainant had suffered grievously seeing her mother being reduced to a vegetative state due to various acts of negligence, omission and commission committed by the OP.

31. Both the parties have filed their respective evidence affidavits and their written arguments. OP has relied on Achutrao Haribhau Khodwa Vs. State of Maharashtra (1996) 2 SCC 634, Chandulal Gokaldas Patel Vs. Dr. Harshad V. Kamdar IV (2003) CPJ 521, Nanish Pathak Vs. Gagabhai Chikabhai Mkwana III (2005) CPJ 100, Martin F. D’Souza Vs. Mohd. Ishfaq 2009 CTJ 352 (SC), Kusum Sharma Vs. Batra Hospital (2010) 3 SCC 480, Vinod Jain Vs. Santokba Durlabhji Memorial Hospital passed by the Hon’ble Supreme Court on 25.02.2019, Bolam Vs. Friern Hospital Management Committee, Maynerd Vs. West Midlands Regional Health Authority, Dr. Chanda Rani Akhouri Vs. Dr. M.A. Methusethupathi CA No.6507/2009 on 20.04.2022. Complainant has relied on Jacob Matthews Vs. State of Punjab, Nizam Institute of Medical Sciences Vs. Prasanth S. Dhanaka (2009) 6 SCC 1, V. Kishan Rao Vs. Nikhil Super Speciality Hospital (2010) 5 SCC 513.

32. This Commission has gone through the entire material on record. It is grievance of the complainant that her mother i.e. the patient in the present case being 89 years 07 months should have been managed conservatively instead of the OP resorting to aggressive and invasive treatment.  It is alleged that blood samples were taken several times a day causing the patient to have thrombophosis and no cogent reason was provided by the OP to put the patient on ventilator support. It is further alleged that Parkinson medicine was stopped for five days which led to further neurological damage of the patient.  It is also stated that within 15 days of hospitalization two angiographies were done on the patient.

It is seen that that the patient was an octogenarian person who was being taken good care of by the family but at the same time it is the family which brought the patient to OP’s hospital thrice in quick succession which signifies that family was aware that the patient needed medical treatment/care which could not be done at home.  It is also seen from the daily medical record of the patient that though one time her antibiotics were recommended to be stopped yet the general condition of the patient was reported as unwell and weak. It is further stated by the complainant that though the case sheet did not recommend blood sugar test as many as 32 blood sugar tests were done on the patient and no reports were provided. The OP has stated that the patient was critically ill and hence repeated blood tests were done to monitor renal function, infection status and coagulation profile. Reports were daily monitored and entered into nursing notes.  It is stated that all due precautions of nursing care were taken for prevention and treatment of bed sores.

This allegation of the complainant stands verified from the bills on record that the patient was charged 32 times for blood sugar glucometer but the daily medical record of the patient neither recommends it nor records the findings of the blood sugar, though the OP has stated that the reports of blood sugar were entered into daily nursing notes however, no record of the same has been placed by the OP.

In the present case, angiography was done twice which as per the complainant should not have been done as there was no abnormality in heart. The OP had provided an explanation for it that the ST Elevation of the patient was high and the Trop-1 Test was also indicating towards heart failure which was considered life threatening due to ventricular tachycardia and therefore angiography was done the second time.  Hence an aggressive line of treatment was adopted in the best interest of the patient and after taking return informed consent. It is stated that urgent coronary angiography and possible angioplasty is the preferred modality for ST elevation even in even an elderly patients and is likely to save lives.

As far as the allegation of the patient being put on ventilator is concerned, OP has answered that only permission was taken and she was not actually put on ventilator. However, it is seen that that the patient has been charged for it.

It has not been denied by the OP that the relatives of the patient found the patient lying in her own faeces on one occasion which incident has been explained by the OP by stating that they were in the process of cleaning the patient when the relatives of the patient came inside the ICU. 

It is further explained by the OP that since the patient was having cardiovascular abnormalities in the form of arrhythmias and Sick Sinus Syndrome it was a justified step to withhold anti Parkinson’s medication.  It is stated that stopping of these medicines for short duration will not have any major side effect. The medication was reintroduced for ruling out the drug side effect.

The Hon’ble Supreme Court in Jacob Mathew Vs. State of Punjab has laid down the test of medical negligence

(3) A professional may be held liable for negligence on one of the two findings: either he was not possessed of the requisite skill which professed to have possessed, or, he did not exercise, with reasonable competence in the given case, the skill which he did possess.  The standard to be applied for judging, whether the person charged has been negligent or not, would be that of an ordinary competent person exercising ordinary skill in that profession.  It is not possible for every professional to possess the highest level of expertise or skills in that branch which he practices.  A highly skilled professional may be possessed of better qualities but that cannot be made the basis or the yardstick for judging the performance of the professional proceeded against on indictment or negligence.

(4) The test of determining medical negligence as laid down in Bolam’s case (1957) 1 WLR 582 holds good in its applicability in India……

In V.P Shantha vs IMA AIR 1996 SC 550 It was held that the skill of a medical practitioner differs from doctor to doctor and it is incumbent on the complainant to prove that a doctor was negligent in the line of treatment that resulted in the life of the patient.

In Mohammed Abrar vs Dr. Ashok Desai decided by the Hon‘ble NCDRC in FA No. 125/2006 it was held “the medical practitioners cannot be treated as magicians or demigods they are falliable human beings…”

In Kusum Sharma vs Batra Hospital AIR 2010 SC 1250 it was held it is a matter of common knowledge that after happening of 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. A professional deserves total protection.”

In the present case, this Commission is of the view that the doctors treating the patient are not guilty of medical negligence as they have merely adopted one line of treatment with which the complainant may not have been agreeable but they were informed by the OPs and consent taken.  It has been held in various judgments on medical negligence that a medical practitioner would be liable only various conduct fell below that of the standards of a reasonably competent practitioner in his field.  The present case is not the one where the medical practitioner’s standards have fallen below the standards of a reasonably competent practitioner in his field. This Commission is of the opinion that the allegation on OPs for the death of the patient when the patient was in an advanced age and suffering from Parkinson disease and was admitted to the OP hospital thrice in quick succession, is unwarranted.

This Commission is however, of the view that there has been unfair trade practice on the part of the OP hospital in conducting investigations which were neither required, advised and for which no reports were provided though the complainant was charged for the same. Likewise, the complainant has been charged for ventilator support items which will probably not used as per the statements of the treating doctors of the patient. Therefore, this Commission directs the OP1 to pay a sum of Rs. 50,000/- as compensation for unfair trade practice within 3 months from the date of the pronouncement of the order failing which OP 1 would be liable to pay interest at the rate of 6% on the said amount till realization.

Copy of the order be provided to the parties as per rules. File be consigned to record room. Order be uploaded on the website.