1.      The Appellant filed the instant Appeal under section 19 of the Consumer Protection Act, 1986, (in short “the Act”), against the Order dated 04.01.2019 passed by the A.P. State Consumer Disputes Redressal Commission, Vijayawada (the “State Commission”) in CC No. 68 of 2012, wherein the State Commission partly allowed the Complaint filed by the Complainants (Respondents herein) against the Opposite Party (Appellant herein).

2.      There is 9 days delay in filing the present appeal. For the reason stated in IA No. 4259/2019 the delay is condoned.        

3.      For convenience, the parties in the present matter are being referred to as per the position held in Consumer Complaint before the State Commission. Complainant No.1 P Narsaiah is a Govt Teacher working in AP Residential School (BC) at Nagarjuna Sagar of Nalgonda District and Complainant No. 2 is his son, pursuing higher education. The wife of Complainant No. 1 and mother of Complainant No. 2 Smt P. Vljaya Lakshmi (the Patient or deceased) was a School Assistant in Zilla Parishad High School, Tirmalgiri, Anumula Mandal, Nalgonda District drawing salary of Rs.25,000/-. Sanjeevani Emergency Hospital is the Opposite Party (OP).

4.      Brief facts of the case, as per the Complainant, are that on 26.04.2010, the wife of the Complainant No. 1 developed fever and allergy and it subsided after taking paracetamol. By 28.04.2010, she felt uneasy and dizzy, prompting a visit to OP hospital. She exhibited symptoms such as sweating and headache. Various tests were conducted including checking BP, Chest X-ray, ECG, CBC, CUE, and initiating saline treatment. At 7:00 PM on the same day, a doctor who is an MD. Physician and General Surgeon attended to her for 20 minutes, indicating no specific treatment was required based on initial observations. However, the doctor recommended more tests including CBP, Dengue, Chikungunya, RBS and Echodoscopy (which was not performed). At around 8:00 PM, Volos D injection and other tablets were administered, with a recorded BP of 100/60, and no cardiologist attended to the patient. Through the night, her condition deteriorated, with complaints of chest discomfort and restlessness. Despite requests, specialist doctors did not attend to her. Medical staff failed to address abnormalities. Even when symptoms significantly escalated, the patient did not receive adequate attention and treatment at the Opposite Party Hospital. Consequently, she passed away in the early morning of 29.04.2010.

5.      The Complainants alleged that abnormal blood pressure readings were not addressed promptly, with pulse rate documentation being altered in the medical records. They accused the hospital staff of negligence and failure to communicate the patient's condition during the 12-hour observation period, despite conducting two ECGs (at 4:15 PM on 28.04.2010 and 3:05 AM on 29.04.2010). The initial ECG was not included in the records and the subsequent one was tampered with, indicating it was conducted on 28.04.2010. They asserted that the medical records were manipulated and that the doctors neglected to conduct thorough investigations promptly and delegated responsibilities to inexperienced personnel, resulting in a worsening of her condition. Despite she being in a hypertensive state since 7:00 PM on 28.04.2010, and experiencing a gradual decrease in BP, the hospital failed to call a cardiologist or recommend transfer to another facility, despite having adequate time. Although the BP readings were not recordable at 3:00 PM on 28.04.2010, the medical staff failed to act. There was negligence and deficiency in medical care on the part of the hospital, resulting in her death. This caused them mental agony, pain, and inconvenience. Had she survived, she would have contributed to the family's income for 15 years. Her monthly salary was Rs.24,792/- as of 28.04.2010 along with other benefits and perks. They sought Rs.97,44,412/- as compensation.      

6.      In reply, the Opposite Party (OP) contended that the complaint lacks merit. The OP acknowledged admitting the patient to their hospital upon referral by a local gynaecologist, with symptoms including fever, skin rashes, headache, nausea and sweating. Due to the severity of the patient's condition, the OP conducted thorough tests and administered treatment in accordance with established medical practices. They ensured the Complainants were informed of the risks, consequences, and the treatment plan. The OP stressed their hospital's comprehensive infrastructure, advanced equipment, and adherence to standard emergency treatment protocols. They refuted any claims of negligence by attending physicians, highlighting the clarity of the case sheet and discharge summary. Further, the OP clarified that the patient, who had a history of rheumatoid arthritis and was on steroid therapy, succumbed to septic shock, resulting in adult respiratory distress syndrome and cardiac arrest. Septic shock, characterized by a dangerous drop in blood pressure due to bacterial infection, led to multiple organ failure, including respiratory failure, and ultimately contributed to the patient's demise. Given the patient's immunocompromised state due to prolonged steroid usage, the OP followed established protocols for managing septic shock but unfortunately could not prevent the patient's death due to the high mortality rate associated with this condition.

7.      As regards documentation, the OP explained that only one ECG was conducted upon admission on 28.04.2010, with a minor error in the date printing, promptly corrected with the correct date and attendant's signature. They vehemently denied tampering medical records and stressed the continuous monitoring and diligent efforts of their medical team, comprising of doctors, nurses and paramedical staff. Despite their best endeavours, the patient could not be revived and was declared deceased around 6:45 AM. The OP emphasized their extensive experience in medical field and reiterated commitment to provide exemplary care to patients. They asserted Complainants failure to disclose the patient's health history, including ongoing treatment for fever and gynaecological issues, which significantly influenced the outcome. The allegations are false, vexatious, and arbitrary and urged for dismissal of the complaint.

8.  The learned State Commission vide order dated 04.01.2019 partly allowed the Complaint with following Order /Relief: -

  “In the result, the complaint is allowed in part awarding a sum of Rs. 29,81,760/- (Rupees Twenty Nine lakhs Eighty One Thousand Seven Hundred and Sixty only) to the complainants and the opposite party is directed to pay the said amount within 8 [Eight] weeks from the date of this order with interest at 9% per annum from the date of the complaint i.e., 21.06.2012 till realization.”

9.      Being aggrieved by the impugned order dated 04.01.2019, the Appellant /OP has filed this present Appeal No. 422 of 2019 with the following prayer:

a) Allow the Appeal arid set aside the Order dated 04.01.2019 passed in G.C.No.68/2012 passed by the A.P: State Consumer Disputes Redressal Commission, at Vijayawada, and dismiss the complaint, and

b) Pass such other orders as this Hon'ble Commission may deem fit and proper in the circumstances of the case.

10.   In the Appeal, the Appellant mainly raised the following grounds:

1. The State Commission failed to take note that the patient did not exhibit any cardiac symptoms during the 16-hour stay at the hospital, thus cardiologist services were deemed unnecessary. They highlighted the absence of previous treatment records and reports filed by the Complainants.
2. The State Commission failed to consider the opinion of the Cardiologist- Dr. NS. Ramaraju, who diagnosed the patient with Septicemia shock with ARDS, emphasizing the absence of cardiac symptoms and the normal baseline ECG.
3. The summoning of a cardiologist was unnecessary based on the expert opinion and the absence of heart complaints. Moreover, General Physician Dr. Valluri Soma Sekhar M.D. (General Medicine), Dr. Gowri Prasad Intensivist and the other team of doctors rightly felt that there was no necessity to call for any other expert much-less Cardiologist.
4. The State Commission failed to see that discrepancies in the ECG recording prompted manual correction by the technician and treating doctor, with the original report provided to the attendants. There was no fabrication since the original report was already in the possession of the Complainants.
5. The State Commission failed to appreciate the impact of corticosteroid drugs on the patient's immunity, particularly in the context of Rheumatoid Arthritis (RA), a chronic autoimmune disease. They stress that RA compromises the immune system, making the patient more susceptible to infections i.e., the body will have less protection against infectious diseases ranging from colds, flu, bacterial illness such as Tuberculosis.
6. The State Commission failed to see that the patient's treatment history for RA, involving NSAID (Non-Steroidal Anti-Inflammatory Drugs) and HCQ, was not presented indicating lack of understanding of the disease's nature.
7. The State Commission failed to appreciate the chronic nature of RA, suggesting that steroid treatment can obscure disease symptoms and alter blood test results, making it difficult to accurately assess the patient's condition. Since the patient was already on corticosteroid treatment, naturally the blood test report will come differently and not actual.
8. The State Commission failed to see that all the time required for culture tests to yield results, contrasting with the patient's death within 16 hours of hospital admission. The Death Summary was provided with detailed treatment records available in the Case Sheet. Additionally, they note that the administration of Inj. Adrenaline was documented in the Case Sheet, alleviating concerns about its absence in the Death Summary.

11.    The learned counsel for the Appellant reiterated the grounds of the Appeal emphasizing that no expert evidence was presented to demonstrate that the treatment by the hospital was erroneous. The burden of proof rests heavily on the Complainants, who must provide expert testimony and medical literature to establish negligence on the part of the doctors or hospital. In support of this argument, reference was made to the judgment in CP Sreekumar (Dr), MS (Ortho) Vs. S. Ramanujam 2009 (7) SCC 130, which held that the onus of proving medical negligence lies with the Complainant, and mere allegations in the complaint are not considered as evidence. The Counsel further cited judgments in Martin Desouza’s case 2009(3) SCC 1; Malay Kumar Ganguly’s Case 2009(9) SCC 221, and S.K. Junjhunwala Vs Dhanwantri Kaur 2019(2) SCC 282 to reinforce their position.

12.    The learned Counsel for the Appellant further argued that in the present case the patient suffered from Rheumatoid Arthritis (RA), a chronic autoimmune condition causing joint inflammation and damage. RA treatment typically involves NSAIDs initially, followed by disease-modifying drugs and steroids. Steroid use can suppress the immune system, affecting the accuracy of blood tests. Further, the patient's blood test results might not reflect actual conditions. The duration of steroid use doesn't significantly impact this effect. Her treatment history was misinterpreted by the State Commission, which wrongly concluded that essential tests were not conducted. However, relevant tests were indeed performed, considering her condition. The patient, admitted with fever and other symptoms, didn't exhibit typical signs of heart problems. The attending physicians took appropriate measures to stabilize her condition, including giving necessary medicines. Despite the absence of certain details in the Death Summary, the treatment provided was documented. The hospital staff, including specialists, continuously monitored till her unfortunate demise. Expert opinions from cardiologists and critical care specialists were presented, but the Complainant failed to produce expert evidence. Key medical personnel involved in her care were not examined or cross-examined during the proceedings. He relied upon the following judgements in support of his arguments: -

a. Doctor will not be guilty of negligence if he has acted in accordance with the practice accepted as proper by reasonable body in the cases reported, 2002 (1) CPJ 4, 2002 (2) CPJ 100.

b.  Every surgical operation is attended by risk, as such simply because something goes wrong, conclusion of deficiency cannot be drawn: Shanta Ben's 2005(1) CPJ 10.

c. In Dr. S.C. Lahri's case, 2008 CPJ 372 NC, it was observed that one cannot expect that every doctor or surgeon is gifted with extraordinary skills to perform miracles.

d. The State commission erred in observing that the consent was not taken as per Samir Kohli's case, 2008 (2) SCC (1). It is submitted that Dr. Praveen Reddy, related to the respondent as such the question of not appraised the details of the treatment to him does not arise.

e. In Ms. INS. Malhotra Vs. Dr. A. Kriplani & ors. (2009)4 SCC 705, it was observed that so long as a doctor follows a practice acceptable to the medical profession of that day, he cannot be held liable for negligence merely because a better alternative course or method of treatment was also available or simply because a more skilled doctor would not have chosen to follow or resort to that practice or procedure.

13.    The learned Counsel for Respondent/Complainant reiterated the facts stated in the complaint and affidavit of evidence filed before the State Commission. He asserted that the patient neither had any gynaecological issues nor sought treatment from the Gynaecologist, who is reportedly a close relative of one of the doctors at the OP hospital. The duration of steroid usage deemed as prolonged was disputed with cross-examination of Dr. NS Ramaraju, Cardiologist, highlighting that mere 10 days of steroid usage does not qualify as prolonged. It was emphasized that cardiac problems cannot be ruled out without investigations such as ECG, 2D Echocardiogram, and Treadmill test. The failure to examine Dr. V Soma Sekhar, MD General Physician, and Dr. Gowri Prasad raised questions, as no explanation was provided by the OP for this omission. Further, concerns were raised about the necessity of conducting tests for Chikungunya and Malaria when she did not exhibit symptoms of fever suggested lack of prudent medical judgment by the OP hospital.

14.  The Counsel for the Complainants / Respondents relied upon the following judgements & Medical Literature: -

(a) Nizam’s Institute of Medical Science Vs. Prasanth S. Dhananka & Ors. (2009) 6 SCC 1.

(b) Savita Garg (Smt) Vs. Director, National Heart Institute (2009)3 SCC 1.

(c) Sanjeev Sunil Kumar Gupta (Dr.) Vs. kamala Velayudhan-III (2011)  CPJ 25.

(d) Dr. Ramesh Iyer & Anr Vs. Uma & Bhat, In First Appeal No. 229 of 2017, NCDRC.

(e) Medical Literature on Dobutamine Injection.

15.    I have examined the pleadings and associated documents placed on record and rendered thoughtful consideration to the arguments advanced by learned Counsels for both the parties.

16.    The primary issue revolves around whether the treatment provided by the Opposite Party (OP) Hospital met the expected standards and whether any deviations from these standards resulted in death of the patient within a day in the Hospital.      

17.    Undisputedly, the patient was admitted to the Opposite Party (OP) hospital on the evening of 28.04.2010 due to complaints of fever, headache, nausea, and sweating. The patient had a medical history of Rheumatoid Arthritis (RA) and was undergoing treatment with NSAIDs and use of steroids for 10 days. Her condition deteriorated during her stay at the hospital itself, leading to her demise within about 16 hours of admission in the morning on 29.04.2010. Medical records confirm the patient's admission to the hospital, the treatments administered, and the sequence of events leading up to her death. The hospital conducted various tests and provided medical interventions during the patient's stay, as documented in the medical records.

18.    It is uncontested position that the patient reported with symptoms of sweating and headache and was admitted to OP Hospital on 28.04.2010. She was examined by the doctors of OP Hospital and, after evaluation of her condition, certain tests and procedures were prescribed. Clearly, the onus to undertake the prescribed tests, monitor her health condition and take steps for care, especially critical care rests with the OP hospital with primary focus on ensuring patient safety and well-being. However, in the present case, despite specific requests from the Complainants and deteriorating condition to extreme emergency levels, she was not paid adequate attention and treatment till she finally died within few hours in the Hospital itself. While the OP contended that her death was due to septic shock, attributing it to prolonged steroid use, which purportedly led to immune deficiency and ultimately a fatal cardiac arrest, this ought to have been recorded as part of admission details, diagnosis and necessary treatment for the same. However, it was neither done nor even attempted. 

19.    As regards the question whether administration of steroids for about 10 days constitutes prolonged use, the OP asserted that the patient's pre-existing condition of Rheumatoid Arthritis (RA) had already rendered her immunosuppressed due to extended steroid usage. This contention was supported by RW-1 Dr. V Sundara Rao. However, the learned State Commission noted that while steroids are known to induce immunosuppression, the Discharge Summary of the patient indicated that she had only been on steroids for 10 days for her RA. Dr. NS Rama Raju clarified that a 10-day steroid regimen cannot be considered as prolonged usage. In this context, reference to an article titled "Monitoring Long-Term Oral Corticosteroids" authored by Lewis Mundell, Medical School Office, University of Dundee School of Medicine, Dundee, UK. According to the National Institute for Health and Care Excellence (NICE) cited in the article, long-term oral corticosteroid use is defined as treatment lasting more than 1 month. Therefore, a 10-day course of steroids does not constitute prolonged use in the context of medical treatment.

20.    The patient was admitted with symptoms of sweating and headache. In addition she was a known case of hypertension and Rheumatoid Arthritis (RA) and using steroids for 10 days. Despite these symptoms and medical history, necessary assessment tests were not done to rule out potential cardiac issues. The Complainant asserted that the ECG reports were suppressed, and a fabricated report was introduced to conceal negligence. However, the OP contended that an ECG was conducted upon admission, albeit with a printing error in the machine date, which was corrected manually. The physician reviewed the ECG and deemed it to be within normal limits. In response, RW-2 Dr. Ramaraju, a cardiologist, clarified that in patients with hypertension or suspected cardiac issues based on symptoms or existing investigations like ECG, X-ray, etc., referral to a cardiologist and further evaluation with tests such as ECG, X-ray, and echocardiogram is warranted. Thus, given the patient's symptoms and medical history, a cardiac assessment should have been pursued by the OP doctors, which has not been done. Therefore, despite her presenting symptoms and medical history, the Hospital's failure to promptly detect and respond to critical signs upon admission points to negligence. Immediate admission should have triggered thorough assessment and monitoring of the patient's condition, especially given her medical history. The OP Hospital's failure to detect and respond to worsening symptoms during the patient's stay in the Hospital itself indicates negligence. Symptoms such as chest discomfort, breathing difficulties, and declining vital signs should have prompted urgent medical intervention and escalation of care to critical care. The lack of timely reaction and appropriate interventions as the patient's condition deteriorated highlights negligence. Medical staff should have promptly recognized the severity of the situation and taken immediate steps to address it, including consulting cardiologist specialists and initiating critical care measures. Ultimately, the patient's death underscores the gravity of the negligence. The failure to detect and respond to the patient's deteriorating condition in a timely manner directly contributed to the tragic outcome, indicating a breach of the standard duty of care expected from medical professionals and the healthcare facility.

21.    Evidently, there is no need to delve further into the negligence of the OP. The “things speak on its own” the principle of “Res Ipsa Loquitor” applies squarely to the case at hand. It is clear that there was deficiency in the services provided by the OP Hospital, Sanjeeveni Emergency Hospital, which was expected to maintain the high standards of essential infrastructure and services in ensuring patient care. However, it failed to meet these expectations, demonstrating both deficiency and unfair trade practices. Therefore, the negligence in this regard is writ large.

22.    Negligence as defined by the court in Jacob Mathew v. State of Punjab (2005)SSC(Crl)1369 that the breach of duty which one party owes to another. The duty can be in the form of an act or omission and it is referred to as the duty of care and due to the negligence of which it causes an injury to the person. In the case of medical negligence, it is the failure of medical practitioners to exercise certain acts or omission while discharging their duties with respect to their patients could not be saved.

23.    In the case of Spring Meadows Hospital & Anr Vs Harjol Ahluwalia & Anr (1998) 4 SCC 39, Hon’ble Supreme Court in wherein it has been observed:-

“9.    …..   Very often in a claim for compensation arising out of medical negligence a plea is taken that it is a case of bona fide mistake which under certain circumstances may be excusable, but a mistake which would tantamount to negligence cannot be pardoned. ……..

10.      Gross medical mistake will always result in a finding of negligence.  Use of wrong drug or wrong gas during the course of anaesthetic will frequently lead to the imposition of liability and in some situations even the principle of res ipsa loquitur can be applied.  Even delegation of responsibility to another may amount to negligence in certain circumstances.  A consultant could be negligent where he delegates the responsibility to his junior with the knowledge that the junior was incapable of performing of his duties properly.”

As discussed (supra), this is a case of “Res Ipsa Loquitor”. 

24.   In view of the aforesaid discussion, it was the case of Res Ipsa Loquitor. Furthermore, it is conspicuous that there exist both a deficiency in service and an unfair trade practice on the part of the OP Hospital - Sanjeevni Emergency Hospital. This hospital was expected to uphold the high standards of essential infrastructure, patient care, protocols, and management, all of which it failed to provide.
Hence, the order passed by the Learned State Commission stands well-reasoned and justified. Upon careful review, I find no reason to interfere with the same. Therefore, the present Appeal is Dismissed.

25.    There shall be no order as to costs. All pending Applications, if any, stand disposed of.

26.    The Registry may release the amount, if any, deposited by the Appellant before this Commission or the State Commission, with interest, if any, accrued to the Appellants, after compliance of the order of the learned State Commission.