Before the District Consumer Dispute Redressal Commission [Central District] - VIII,      5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi

                                      Complaint Case No.286/28.08.2014

Jiwachh Jha son of Late Yogendra Jha

Present r/o E-603, Mahaveer Tranquil 2^nd Main,

Nallurhalli, P.O.: Whitefiled, Bengaluru-560066

Permanent  r/o  8 G.M. Road, near Ram Janaki Hospital,

Rajkumarganj,  P.O. – Lalbagh, District – Darbhanga

(Bihar) PIN- 846004                                                            ...Complainant

 Versus

OP1. M/s Sir Ganga Ram Hospital

Rajinder Nagar, New Delhi – 110060

OP2.  Dr. D.S. Rana, Nepphrologist,

Sir Ganga Ram Hospital,  Rajinder Nagar,

New Delhi – 110060

OP3.  Dr. Anurag Gupta, Nephrologist

Sir Ganga Ram Hospital  Rajinder Nagar,

New Delhi – 110060                                                   ...Opposite  Parties

                                                                                    Senior Citizen Case

                                                                                    Date of filing              28.08.2014

                                                                                    Date of Order:            20.12.2023

Coram:

Shri Inder Jeet Singh, President

Ms. Shahina, Member -Female

                                                       ORDER

Inder Jeet Singh , President

1.1.(Status of parties in the case) -  This complaint was filed by complainant/Sh. Jiwachh Jha u/s 12 of the Consumer Protection Act, 1986. He is husband of Smt. Saroj Devi (since dead, hereinafter referred as 'patient' or 'wife of complainant' or otherwise by her name) and she died during her treatment as indoor patient of OP1/Sir Ganga Ram Hospital, Rajendernagar, New Delhi-110060. She was initially an OPD patient [for ailment of Nephritic Syndrome- FSGS] but hospitalized as an indoor patient on advice of OP2/Dr. D.S. Rana, Nephrologists, who was treating her since 09.05.2012 as an OPD patient. OP3/Dr. Anurag Gupta, another Nephrologists,  was a team member of OP2 during hospitalisation of patient. Smt. Saroj Devi was receiving treatment as an indoor patient for her renal and allied ailments vide registration no. 1161751 under OPs from 28.08.2012 till she expired on 08.09.2012 in the Hospital.

1.2. (Introduction to dispute) –The complainant has grievances that his wife was hospitalized on 28.08.2012 and she died on account of bad diagnosis, wrong treatment, gross negligence and inhuman approach on the part of OP1/Hospital and its attending doctors/OP2 & OP3. She had walked to the hospital on her own on 28.08.12 but died there. The complainant seeks compensation of Rs.18,20,000/-, costs of litigation of Rs.40,000/- and interest besides  other appropriate relief.

             But the OPs in their joint written statement deny all such allegations of bad diagnosis, wrong treatment, gross negligence and inhuman approach vis-a-vis OPs diagnosed rare disease in patient suffering from. The OP1 has high morality towards its patient and she was given the best and timely treatment needed. The complainant is not entitled for any of the reliefs sought for.

1.3. (Original medical record/papers) - The complainant had alleged that there was manipulation or subsequent writing on the existing record.  The complainant filed an application for direction to place on record the original medical papers of the patient, the same were filed by OP1, which are part of record of the complaint file. The record also comprises progress notes/investigation order under the writing of attending doctors [its photocopies were already filed with the complaint, the photocopies filed by complainant are of the originals] besides original clinical chart -ward & nurse notes [its copies were not with the complaint].

1.4. (Expert opinion) - As per proceedings dated 12.01.2016 of this case, the matter was referred to LNJP Hospital & Maulana Azad Hospital for expert opinion and record was also provided to them. Then report of Committee of three senior panel of Doctors was received [opining viz (i) the doctors treating the patient were well qualified to treat the patient, (ii) doctors have given treatment according to the condition/illness of the patient and (iii) there was no evidence of negligence in this case].  However, the complainant had objections to the report being without  reasons, but the OPs refers expert report in their support.

1.5. (Other factors) -  The complaint has been in narrative with minute details including of date, time, visiting doctors, condition of patient and attending of patient from time to time, nature of treatment, tests, investigation, prescriptions etc. Similarly, the OPs in their reply have also given minute details of treatment with clinical and pathological reports; they also mention medical literature/journals in their support.  In the same way, when case was at evidence stage, these features have been repeated, which were further reiterated at the stage of final arguments.  Therefore, it will be appropriate put the case of each party at one place for the sake of brevity and clarity vis a vis to avoid repeating them, especially record is voluminous. It will be narrated in forthcoming paragraphs 2 and 3 of this final order.

1.6  (Medical terminology with simple ordinary meanings ) - Since, the complainant's wife was OPD patient of OP2 prior to 28.8.2012 and then IPD under OPs w.e.f. 28.8.2012 till she died on 8.9.2012 in the Hospital, the patient was subjective to various examination, tests, investigation,  treatment etc.  There are many medical terminology mentioned progress notes, investigation orders, clinical chart of  the patient, however, they are not explained.  They are material and relevant to mention with its simple meanings to apprehend the nature of disease, its diagnosis, tests and treatment and also  to appreciate the rival plea and to unfold circumstances. The same are being introduced at this stage -

(A) Electrolyte imbalance - An electrolyte imbalance occurs when one has too much or not enough of certain minerals in the body. This imbalance may be sign of a problem like kidney disease. Electrolytes are minerals that give off an electrical charge when they dissolve in  fluids like blood and urine.

(B) Nephritic syndrome  (FSGS) - Nephritic syndrome  (FSGS)  is a clinical syndrome that presents as  hematuria elevated blood pressure, decreased urine output and edema. The major underlying  pathology is inflammation of glomerulus that results in nephritic syndrome. 

            Nephritic syndrome (NS) is kidney disorder that  causes the body to excrete too much protein in the urine. NS is often caused by damage to small blood vessels in the kidney that filter waste and excess water from blood. An underlying health condition usually plays a role.  Its symptoms includes swelling around face, eye socket, legs, arms, hands, feet, ankles, abdomen or other areas are common symptoms of FSGS, besides other symptoms. Its treatment consists of steroids and immunosuppressant. The treatment addresses underlying conditions and might include blood pressure medication and  water pills.

(C ) Hypothyroidism -  A condition in which the thyroid glands does not produce enough thyroid hormone.  Hypothyroidism's deficiency of thyroid hormone can disrupt such  things as heart rate, body temperature and all aspects of metabolism.  Generally, hypothyroidism mostly prevalent in older women. Its major symptoms also includes fatigue, gold sensitivity, constipation, dry skin and unexplained weight gain. The diagnosis is usually based on blood tests.  Its treatment consists of  hormone medicine/replacement

(D) Hypertension - A condition in which the force of  blood against the artery walls is too high.

(E) P/W Hyponatremia - Hyponatremia is low  concentration sodium in the blood. It is a common electrolyte disturbance frequently requiring fluid administration for correction to physiologic levels.

Its common symptoms are headache, insufficient urine production, mental confusion or nausea. For its treatment, hypertonic saline (NaCl) is given as an effective and potentially life saving treatment

(F) Hypokalemia - It is also known as low blood potassium level.  The body get potassium through food one eats. A blood level that is below normal in potassium, an important body chemical.  It results in fatigue, muscle cramps and abnormal heart rhythms and accordingly symptoms are reflected.  Hypokalemia happens by an excessive loss of  potassium in digestive tract due to vomiting, diarrhea or laxative use.  It is treated by oral potassium replacement or IV as per potassium level.

(G) Constipation - the constipation happens because of colon absorbs too much water from the poop, this dries out the poop making it hard in consistency and difficult to push out of the body.

(H) Duodenitis infection- duodentitis is inflammation in the duodenum, the first or most upper part of the small intestine (located just below the stomach). It can cause abdominal pain,  bleeding and other digestive symptoms. For its primary treatment, antibiotics are generally prescribed and administered besides variety of fruits and vegetables.

(I) Invasive parasitosis - Parasites are organisms that live off other organisms, or hosts, to survive. Some parasites do not noticeably affect their hosts.  But other parasites grow, reproduce or invade organ system that make their host sick, resulting in parasitic infection.

            It may be diagnosed with blood test, a fecal exam (stool examination), and endoscopy (if stool examination is inconclusive) and also X-ray/MRI/CT scan to check signs of lesions or injury to organs caused by parasites. They are treated by medicine and other hygienic preventions.

(J) Strongyloidiasis - is a parasitic infection caused by species of intestinal nematode or a roundworm in the genus strongyloide.

            Those people who develop symptoms often have generalised complaints, as some people develop abdominal pain, bloating heartburn, intermittent episode of diarrhea and  constipation, dry cough and skin rashes. Strongyloidiasis infection is best diagnosed by blood test and it may also be diagnosed by seeing larvae in the stool but it may not be found in all the infected patient.  For treatment, Ivermectin is used as more effective than albendazole.

(K) Disseminated strongyloidiasis- Disseminated strongyloidiasis means widespread dissemination of larvae outside the gut and lungs, often involving the liver, brain, heart and urinary tract.

(L) E.Coli. (Escherichia coli)- It is a type of bacteria, most commonly in raw or uncooked hamburger meat. Infection can be spread through contact with contaminated food or water. Its symptoms include diarrhea, stomach cramps and occasionally fever

(M) Gram negative sepsis in form of E.Coli.- E.coli is a gram negative bacillus known to be a part of  normal intestinal flora but can also be the cause of intestinal and extra-intestinal illness in humans.

(N) tachycardia   (fast heart rate)- A rapid heartbeat that may be regular or irregular but is out of proportion to age and level of  exertion or activity

(O) wide complex tachycardia (WTC) - a cardiac rhythm with a rate >100 beats per minute and a QRS width >120 milliseconds. It is serious condition, as its major contributor to sudden cardiac death and  appx. 80% WTC case are due to VT.

(P) Sclerosis - a disease in which the immune system eats away at the protective covering of nerves. Multiple sclerosis is caused by  immune system mistakenly attacking the brain and nerves.

(Q) Vasculitis - Vasculitis is an inflammation  of the blood vessels. It happens  when the body's immune system attacks the vessels by mistake.  It can happen because of  an infection,  a medicine,  or another disease.

(R ) Kala-azar-  Kala-azar is slow progressing indigenous disease caused by  protozoan parasite of genus Leishmania . In India Leishmania donovani is the only parasite causing this disease. The parasite primarily infects reticuloendothelial system and may be found  in abundance in bone marrow, spleen and liver.

(S) septicemia - it is infection of the blood by poisonous bacteria.  It is an infection caused by large amounts of bacteria entering the bloodstream.

(T) general anasarca - Anasarca is a medical condition that leads to general swelling of the whole body. It happens when the body tissues retain too much fluid due to several reasons. However, it is different from other type of edema that affects one or two parts th body.

(U) Cause of death - septic shock* with duodenitis with invasive strongyloidiasis** with LRTI# with dyselectrolytemina##

antecedent cause - nephritic syndrome-

[*Septic shock is a life threatening condition that happens when blood pressure drops to a dangerously low level after an infection. [Septic shock is third/last stage, the first stage is sepsis  and second stage is  severe sepsis.

**invasive strongyloidiasis - an invasive disease is one that spreads to  surrounding tissues.

#LRTI means Lower respiratory tract infection, it occurs when there is infection in lungs especially in lower airways. This infection is usually caused by  bacteria or  other less common  organisms.

## dyselectrolytemina -dyselecrolytemina  is an imbalance in the required amount of electrolytes  which are sodium, potassium, calcium, magnesium and chloride in the blood. The symptoms include are vomiting, nausea, fatigue, seizure an headaches etc. This may be  a result of excessive loss of  fluids which in turn give rise to this disorder].

2.1. (Case of complainant) -  The complainant's wife Smt. Saroj Devi was initially OPD patient under OP2 and she was advised admission in OP1.  During her primary investigation, the OPs advised that she was suffering from electrolyte imbalance, it would be managed in ward but she was not treated and managed properly after hospitalisation. The abdominal symptoms of the patient were on decline. She was unable to take orally. She was vomiting, whatever meager food was being taken. Her health/weight went on deteriorating but no care was done for that by OPs. Moreover, nothing was being done for her nutritional support.

There was negligent attitude of OP2 & OP3 -consulting/attending doctors and of other authorities of OP1, which manifests from schedule/chart of the treatment. The chart was provided at a very belated stage, and that too, after repeated demands from the hospital authorities of OP1. This chart  of the hospital authorities (at page 1 to 68 of paper-book) was edited and several particulars were added and changed by OP3 in consultation with other doctors for more than an hour before the eyes of representative of complainant on the same very date of the delivery. The complainant had also requested OP2 to bestow his personal attention to patient instead of deputing OP3, being junior doctor for examination. The condition of the patient was deteriorating but due care was not being taken by OPs, particularly OP2. The complainant was considering for to shift his wife to other hospital by bringing it to the knowledge of OPs but OP2 and OP3 persuaded the complainant to continue her treatment in the hospital of OP1.

2.2. On 04.09.2012, OP2 decided for endoscopy of the duodenum and CT scan of whole abdomen of complainant with oral contrast. Accordingly the tests were performed but the I.V. contrast was used instead of using oral contrast for CT scan. On 04.09.2012 she was provided with the central line system in the ward itself as against in the ICU as advised by the attending doctor for conveniently administering drugs. She was administered liquid as IV. contrast material and thereafter referred to CT scan centre in the hospital building for scanning. But the CT scan was performed by the receptionist- a layman himself instead of any radiologist, as observed by the complainant.

2.3. The abdominal symptoms of the patient were not improving. She was unable to take orally as she had started vomiting but no care was taken for that. There was nothing being done for her nutritional support. As per endoscopy report, she had been suffering from infection of the duodenum. She was prescribed Tab. Nizonide by the attending doctor on 06.09.2012 but there was no improvement at all. The complainant along-with his daughter inquired from OPs that as to why a simple stool test was not being done for investigating the duodenum infection but the OPs gave no explanation. Later-on 06.09.2012, they advised stool test, which was sent for examination the next morning but till then it was of no use being belated.

On 06.09.2012 the patient complained of pain in her thighs, back and lower portion but she was not given due attention by the OPs. It was advised to compress locally with hot water bag and they prescribed Inj. perfalgan - SOS. At 7:15 pm Dr. Amit Dhamija, working in the hospital, was called for examining the patient. The attending doctors never explained about the seriousness or the patient’s condition to the Complainant. In the meantime, the doctors told that the patient was suffering from tuberculosis and anti-tuberculosis drugs were started. But on the very next day, they told that the patient was suffering from parasitic infection. The anti-tuberculosis drugs were stopped  but  treatment for parasite was started.  The condition of patient was not improving. Then OPs told the complainant that patient was suffering from sclerosis.

2.4. On 07.09.2012, the patient developed red rashes on her thighs and legs, immediately doctors were informed. Then another medicine Ivermectine was prescribed in place of previous tab. Nizonide. On 07.09.2012 at 4 pm, the blood sample report was available, according to report the platelet counts were 70000, it was brought to the notice of OP2 during his round. The complainant requested to consider, whether blood transfusion would be necessary but the request was ignored. It was evening hour of 07.09.2012 and during the round of the ward suddenly doctor told the complainant that the patient was serious, she was to be shifted to ICU. But ICU doctor told that she was not serious and she could be managed in the ward itself.

            It was about 10 pm, when the patient complained that she was not able to lift her leg. The complainant immediately informed the attending nurse. A Doctor came, who checked her BP and told that there was no matter of anxiety and left. She again complained of her inability to move the legs after  about two hour. Her voice was also trembling/choking. The complainant informed the nurse available at the counter. The nurse came and tried to feel her dwindling pulse and in the meanwhile a junior doctor also arrived. But the pulse could not be recorded, he hastily administered some medicine. Still, the pulse could not be recorded in the machine and there was almost no movement in the patient. She was virtually dead but to save themselves from the complainant’s antagonism and just not show instance of death in the ward itself, her dead body was shifted to ICU and attending doctors tried to befool the complainant. The complainant was asked and required to sign so many papers in the ICU. The complainant was called 3-4 times there.

2.5 On 08.02.2012 at about 6 am, the complainant was called. The attending doctors informed the complainant in a pacifying tone that the patient was not responding even to the highest degree of shocks/ventilator. Ultimately, at around 6:30 am, she was declared dead by ICU doctor, thus putting the complainant’s apprehension as well as the unflinching hope for her recovery to a sad end. She had walked in the hospital on her own for normal treatment process on 28.8.13 but she was converted into a dead body, the OPs failed to take due and timely care to save her life. There is negligence, bad diagnosis, wrong line treatment and mismanagement on the part of OPs, which result into her casualty. The complainant paid entire charges of Rs. 1,87,269/- to OPs.

2.6. In paragraph 20 of the complaint is summary his allegations, which are-

(a). From day one,  the negligent and careless attitude of the respondents was evident. There was complete lack of promptness. The patient was attended in a very casual manner.

(b). The attending doctors never explained to complainant the complete picture of the patient’s condition. The OPs did not inform the complainant about the side effects of the drugs and the CT scan procedure with contrast material. They failed to diagnose the patient’s ailments and went on treating in an aimless manner.

(c). The cause of death was mentioned as “Septic shock with Deuodinitis with LRTI with Dyselectrolytemia” by the hospital. But no effective medicine was prescribed for septicemia. The question arises as to how the patient had developed septicemia when she was not having such complication at the time of her admission. It is clear that septicemia, if any, was caused during her hospitalization with the OPs.

(d). Hypoklemia, i.e., low level of potassium in the blood was reflected every time during investigation. It could have also affected the function of the heart. But no test viz. ECG/Echo etc. was ever done to have an account of the cardiac condition and  accordingly reset the line of the treatment.

(e). For a nephritic patient undergoing CT scan with contrast material has always been fraught with risk as it gives rise to contrast induced nephropathy- a significant source of hospital morbidity and mortality. A combination of several risk factors viz. “pre-existing impairment of renal function, azotemia with diabetes mellitus, nephrotoxic drugs, advancing age, female sex, anaemia, osmalarity etc. were present with the patient’s condition. Still the O.P.s insisted for CT scan procedure with contrast material administered through the central line system without resorting to any preventive measures like temporary haemodialysis/hemofiltration or permanent dialysis notwithstanding the red rashes appearing on her lower body portion associated with pain and low level of platelet count. The procedure finally proved fatal for the patient. It was quite improper, illogical and instance of sheer negligence. The O.P.s failed to think of safe alternative diagnostic procedures like sonography or MRI in such a medical condition.

(f). Urgent cardiology referral and starting “statin +” was advised on 07.09.2012 by the attending doctor but that was ignored by the OPs.

(g). The patient was simultaneously treated for her nephritic condition, parasitic condition, skin rashes, TB etc. that smacks of poor/bad diagnosis of the complications by the attending doctors/OPs and prescribing/administering excessive/wrong medicines including steroid overdose just like hitting in the dark.

(h). The OPs completely failed to manage electrolyte balance since beginning. Besides the patient was administered heavy dose of steroids. But she was not transfused blood despite her anemic condition and low platelet count.

(i). The patient was not promptly shifted to ICU as per earlier advice. Instead she was left in the ward itself despite fully knowing her precarious condition. The shifting was not done even when she first complained of her inability to move her legs. That was indicative of the fact that either the hospital was not having vacant bed in the ICU then or the attending doctors did not take it seriously or acted in a very casual manner. The delay caused her life.

(j). The dead body could be handed over to the complainant only after the huge bill amount was paid in full. There was no time available as to verify the authenticity of the expenditures shown therein. The complainant had to simply believe and go by the demand. But irony of the fact is that the OPs have not developed the decorum of handing over the dead body wrapped in even simple kafan albeit at the cost of the attendants. Alas to mention that the dead body in naked condition covered by sheer paper was handed over to the Complainant.

3.1. (Case of OPs)- The OP1 through its Medical Superintendent, OP2 and OP3 filed their joint written statement, which has been split into preliminary objections, true facts and reply on merits. In the preliminary objections and reply on merits,  deny all allegations of complaint against OPs, with the support of facts mentioned under the heading of true facts.

3.2. The OPs also give details in chorology, which reads as-

(i) Mrs. Saroj Devi, 50/F had first O.P.D. visited to Sir Ganga Ram Hospital on 09.05.2012. She was recently detected to have DM (Diabetic Mellitus) and HT (Hypertension), on evaluation of edema over feet. In 1987 patient had suffered from kala azar, and at that time she also developed DM (Diabetic Mellitus), and received treatment for three months. On evaluation at OP1, she was found to have nephritic range proteinuria, (spot urine protein: creatininie ratio,12.1). Because of want of diabetic retinopathy and normal sized kidneys, she was advised kidney biopsy. The kidney biopsy was suggestive of minimal histological changes-possibility of focal segmental glomerulo-sclerosis was kept. The patient was started on oral steroids. Patient was also reviewed in O.P.D. on 11.07.2012.  Patient’s steroids were tapered and started mycophenolate mofitil, but proteinuria was still persisting.

(ii). Patient came in emergency on 23.08.2012 at 11:46 pm with complaint of abdominal pain and distension and nausea feeling for two days. Investigations sent on that day were suggestive of hyponatremia (117 meq/l) and blood culture was negative. Patient was advised admission but her husband did not follow the advice and signed the leave against medical advice form (LAMA).

(iii). Patient again came to emergency on 27.08.2012 in night at 11:30 pm with complaints of abdominal pain and abdominal distension and loss of appetite. Patient was admitted at night and evaluated. She was found to have low BMI- 17.8 Kg/m2, Edema over lower limbs and abdominal wall edema. The patient was having severe hypoproteinemia 3.1gm/dl and severe hypoalbuminmia: 1.1gm/dl.

(iv). Her urine spot Protein/creatinine ratio was 12.03, which was suggestive of massive Proteinuria. Evaluation of hypothermia (urine osmolality was 534 mosmol/kg, serum osmolality was 224 and urine spot Na was 27meg/L,. Urinary spot Potassium was 15meq/l, which does not show urinary loss. It may be related to mal-absorption. In view of loss of appetite, abdominal distension, abdominal pain, generalized weakness, possibility of abdominal Koch’s with sub-acute intestinal obstruction, with mal-absorption was kept. Patient was started with I.V. 3% saline at 10ml/h and potassium supplementation and fluid restriction. Gastro medicine reference was taken and patient was started on Laxatives. Patients continued to have hyponatremia. Patient was advised to restrict fluid up-to 1000ml and 3% saline and I/V Albumin was given. Patient’s symptoms improved on 30.8.2012.

(v). Patient’s symptoms again worsened in form of constipation, decreased oral intake and vomiting on 31.8.2012. Patient was advised for UGIE, but patient’s attendant was unwilling for UGIE. Patient’s loss of appetite, vomiting and electrolytes abnormality were persisting. Patient’s attendants were counseled about future investigations in form of UGIE, but patient’s attendants were repeatedly refusing any further investigation in form of UGIE on 1.9.2012, 02.09.2012, 03.09.2012. On 3.9.2012 patient’s attendants were explained about poor general condition of the patient to the complainant.  

(vi) On 04.09.2012 at 9am patient was conscious oriented but decreased oral intake and anorexia was present and attendants were not cooperative for the treatment and attendant wanted discharge on request, which was made. But at 11:30am after, again, explaining by Dr. D.S. Rana and Dr. Anurag that patient still needs hospitalization in any hospital and further investigations, and treatment, patient’s attendant became willing for investigations and treatment.

After taking the consent from family, UGIE was done on 04.09.2012, which was suggestive of duodenitis but still diagnosis was unclear. With possibility of GI tuberculosis with obstruction or any other pathology in form of malignancy, CT chest and abdomen was done with oral and I.V. contrast. CT was suggestive of nodular lesions in right middle lobe and B/l pleural effusion, suggestive of infective etiology? Tubercular. Prior to doing the CT scan, S. Creatinine was 0.39 mg/dl.

(vii). On 05.09.2012 patient’s symptoms were persisting and general condition was poor. Treatment was revised by Dr. D. S. Rana/Dr. Anurag. In view of poor oral intake, I/V 3% saline and I/V KCI and I/V Kabivan was given and 24 hr urinary sodium was sent, which was 156 meq/l (40-220meq/l is normal range) which was suggestive of either hyponatremia is dilutional or there is component of mal-absorption.

(viii). On 06.09.2012 case was seen by Dr. D. S. Rana/ Dr. Anurag, in view of persistent symptoms, poor prognosis was explained in detail because of immuno-compromised status of the patient. Chest medicine reference was taken on 6.9.2012, and they suggested starting ATT.

(ix). On 07.09.012 patient was having generalized anasarca and maculopapular rash on bilateral lower limbs. Haematology, dermatology, medicine and chest medicine and vascular references were taken. Dr. Anupama Jaggia kept the possibility of cholesterol immobilisation. Cardiology reference was taken from Dr. Ashwani Mehta, he advised for lipid profile. Skin biopsy was taken by Dr. Bhareja with possibility of vasculitis. On 07.09.2012 duodenal biopsy was suggestive of parasitic infestation compatible with strongyloidiasis, which was a histological surprise. Vascular reference was taken, there was no evidence of DVT. Medicine reference was taken by Dr. P.S. Gupta. Both Dr. P. S. Gupta and Dr. Piyush Ranjan advised ivermectin. Ivermectin was started. Again Chest medicine reference was taken from Dr. Basu and Dr. Dhamija, they suggest lung lesion could be because of strongyloidiasis.

Patient was reviewed in evening at 7:45 pm by Dr. D. S. Rana and Dr. Anurag, she was found to have low platelets 70000/cumm, low TLc (3900/cumm), deranged PT-26.2 sec (control 12.2 sec) deranged APTT-82.2 sec (mean normal was -27.5 sec) and deranged INR, blood culture was suggestive of gram negative bacilli. Possibility of septicemia with DIC was kept.

Patient was started on Inj. Meropenam and other supportive treatment and poor prognosis was explained to the attendants (as mentioned on page no. 80, 81 of the complaint). ICU reference was taken, he advised to continue same treatment and at that time no active ICU intervention was required.

Patient was having abdominal pain started in night at 11 pm, for which pain killer was given (Inj. Tramadol). Again call was attended on 08.09,2012 at 1:10 am by nephrology registrar. Patient was hypotensive, restless, pale, agitated with heart rate of 140/min. Patient was shifted to ICU and intubated at 1:45 am in morning and immediately patient had cardiac arrest and was revived after CPR. Prior to intubation ABG was having PH 6.98 and bicarbonate of 11 and lactate of 8.51, which was suggestive of mixed lactic and metabolic acidosis. Patient was on high ionotropic support and subsequently had two more cardiac arrests and could not be revived and declared dead on 08.09.2012 at 6:30 am.

(x) Investigation send from ICU was suggestive of severe sepsis with coagulopathy with DIC with underlying gastrointestinal bleed. Her hemoglobin was 4.7 gm/dl, TLC dramatically low just 300/cumm, and platelet were 15000/cumm, features of marked pancytopenia, blood culture was positive for Ecoli, PT was 71.9 sec and APPT was more than 250 sec, which suggest severely deranged bleeding parameters.

(xi) Patient suffered from kalaazar in 1984. On review of literature, survey carried out by National Rural Health Mission (2005-2012), 80% of cases of country belong to Bihar and District Dharbhanga. Bihar is endemic for kalaazar. Patient originally belonged to Dharbhanga District. Three cases reports of invasive strongyloidiasis in kala-azar patients are reported in literature (journal of tropical and geographical medicine 1995). Smt. Saroj Devi may be having strongyloidiasis in dormant phase and may be precipitated by immunosuppressive treatment.

Gastrointestinal symptoms are most common but non-specific. Strongyloidiasis may present with gastrointestinal symptoms in form of abdominal pain, constipation, nausea, vomiting, diarrhea, anorexia, gastric distension, mal-absorption and electrolyte abnormalities (Jan 2004, clinical microbiology review). These symptoms occurred in this patient. Skin biopsy was suggestive of small vessels vacuities, which could be secondary to disseminated strongyloidiasis as reported in literature (Jan 2004, clinical microbiology review). Relatively non specific clinical features of this disease lead to diagnostic difficulty. Diagnostic yield of duodenal biopsy is 90%, whereas of stool examination is 30%-50% (journal of tropical medicine, August 2009). OPs did duodenal biopsy in this patient. Disseminated strongyloidiasis is often associated with enteric bacterial infections. It has been hypothesized that intestinal luminal bacteria may accompany the parasite during its transmutable migration across the intestinal wall. In a study published from SGPGI Lucknow, initial clinical diagnosis of strongyloidiasis was not suspected in any of the five cases and three out of five cases had gram negative sepsis in form of E.coli, (journal of tropical medicine, august 2009). In this patient case also there was gram negative sepsis in form of E.Coli. Disseminated strongyloidiasis had mortality as high as 87%. Concurrent septicemia, adds to the mortality (journal of tropical medicine august 2009), which also happened in this patient. There are few case reports from India, largest series of five patients from SGPGI Lucknow, where three out of five patients expired, all of these three patients were also having gram negative sepsis in form of E.coli. So this patient was suffering from disseminatination strongyloidiasis with gram negative septicemia. Another factor which could add to the mortality to the patient was severe malnourishment with serum protein of 2gm/l and serum albumin of 1.3 gm/l.

3.3. The OPs in their reply on merits, also deny  all allegations  of complaint with their  plea [already recorded in sub-paragraph 3.2 above].

Since, the patient was having low BMI (17.8 Kg/m2 ), severe hypoproteinemia, and hypoalbuminemia, hyponatremia, hypokalemia, it was managed with 3% saline, fluid restriction, extra salt, i/v kcl and oral potassium supplementation, and i/v albumin. The patient was managed with liquid and soft diabetic diet, and i/v albumin to compensate for hypoalbuminemia and even parenteral nutrition was started in form l/v kabivan.  Hence the best possible management was provided to the patient. The patient was seen daily at least twice in a day as and there was no negligent attitudes of attending doctor.
OP3/Dr. Anurag is DM nephrology from SGPGI Lucknow and to see patients in Department of nephrology is a team work and every-thing was being informed to OP2/Dr. D.S.Rana on daily basis.  OP2 visited the patient on 29.08.2012, 04.09.2012, 05.09.2012, 06.09.2012, 07.09.2012 (which are mentioned on pages 35, 55, 65, 73, 79 of paper-book).  So, Patient was managed by a well trained and highly qualified nephrology team.

On 04.09.2012 at 9am patient was conscious, oriented but decreased oral intake and anasarca was present and attendant’s were not cooperative for the treatment and attendant wanted discharge on the request, which was made. But at 11.30am,  it was again explained by OP2 & OP3, that patient still needs hospitalization at any hospital for further investigations and treatment.  There was no pressure put on patient's attendant to carry treatment at OP1.  Then the attendant himself was ready for investigations and treatment of patient at OP1 under the treatment of doctors. The U.G.I. endoscopy was done on 04.09.2012, which was non-specific in form of duodenitis.  But diagnosis was unclear.  With possibility of GI tuberculosis with obstruction or any other pathology in form of ‘malignancy’, a CT chest and abdomen was done with oral and IV contrast.   Prior to doing the CT scan, S. Creatinine was 0.39 mg/dl, only oral contrast was given in ward.  l/V contrast was never given in ward in Institute of OP1, it is always given in CT scan room under the vigilance of a doctor. The CT scan machine is operated by well trained technicians. The patient was managed with liquid and soft diabetic diet and I/v albumin to compensate for hypoalbuminemia and even parenteral nutrition was started in form of I/v kabivan. The best possible management was provided to the patient.  Further single tablet was not enough to cause improvement. In patient suffering from disseminated strongyloidiasis in immune-compromised patients suffering from invasive strongyloidiasis, diagnostic yield of duodenal biopsy is 90%, and that of stool examination is 30% - 50% (journal of tropical medicine August 2009). The OPs did their best investigation in patient, which has high yield to diagnose the problem from which the patient was suffering from.

 On 06.09.2010 the patient was having pain in back and lower limbs for which the she was given I/V paracetamol.  CT was suggestive of nodular lesions in right middle lobe and B/I pleural effusion, suggestive of infective etiology? Tubercular. Chest medicine reference was taken from Dr Dhamija, he suggested to start anti-tubercular treatment, the complaint was explained about the gravity of illness.  On 03.09.2012, patient’s attendants were explained in detail about poor general condition of the patient.  On 06/09/2012 case was seen by OP2 and OP3.   In view of persistent symptoms, prognosis was again explained in detail because of immune-compromised status of the patient.   On 07.09.2012 poor prognosis were further explained to the attendants.  So, patient‘s attendants were fully aware about sick condition of the patient. On 07/09/2012 duodenal biopsy was suggestive of parasitic infestation compatible with strongyloidiasis, which was a histological surprise & for which relevant treatment was started.  However, Tuberculosis cannot be entirely ruled out & so ATT was started in modified dose on 07.09.2012.

  On 07.09.2012 patient developed generalized anasarca and maculopapular rash on bilateral lower limbs. Haematology, skin, medicine and chest medicine and vascular references were taken. Dr. Anupama Jaggia kept the possibility of cholesterol remobilization. A cardiology reference was taken from Dr. Ashwani Mehta, he advised for lipid profile. Skin biopsy was taken by Dr. Bhareja with possibility of vasculitis, which could be secondary to disseminated strongyloidiasis. As reported in literature (Jan 2004, clinical microbiology review). So, skin lesion was not related to reaction to contrast material. The patient was reviewed in the evening at 7:45 pm by OP and OP3 and she was found to be having low platelet 70,000/cumm, low TLC 3900/cumm. Blood culture suggestive of gram negative bacilli. The possibility of septicemia with DIC was kept. Patient was not having bleeding from any site, and 70,000 platelets was not indication for platelets transfusion. On 07.09.2012 ICU reference was taken and he advised to continue the same treatment and at that time he advised no active ICU intervention required and best possible management was given in ward. But patient’s condition worsened at 1:10 am in night on 08.09.2012, patient was restless, agitated, pulse was very week. ICU reference was taken immediately. Emergency treatment was given. BP was 70 systolic so when pulse was there BP was 70 systolic, body cannot be dead so alive patient was shifted to ICU.  As per ICU protocol consent paper has to be signed to continue the treatment in ICU. The blood, which is arranged by attendant in blood bank, used to collect by ward boy of ICU, however, by the time blood could be transfused patient suffered two more cardiac arrests and could not be survived. On 08.09,2012, the patient was hypotensive, restless, pale, agitated with heart rate of 140/min. The patient was shifted to ICU and intubated at 1:45 am in the morning and immediately patient had cardiac arrest and patient was revived after CPR. Prior to intubation ABG was having PH 6.98 and bicarbonate 11 and lactate 8.51, which was suggestive of mixed lactic and metabolic acidosis. Patient was on high lonotropic support and subsequently she had two more cardiac arrests and could not be revived and declared dead on 08.09.2012 at 6:30 am.

The patient was suffering from disseminated strongyloidiasis with gram negative septicemia and DIC. The disease stongyloidiasis had mortality as high as 87% and concurrent septicemia adds to the mortality (journal of tropical medicine August 2009) which happened also in respect of this patient. So,  the problem of this patient was not a simple problem.  However, the patient was given full care but she was suffering from a rare problem. There are very few cases of disseminated stronglyloidiasis, which  are reported from India. The largest case series of five patients is from SGPGI, Lucknow. In study published from SGPGI, Lucknow, initial clinical diagnosis of strongyloidiasis was not suspected in any of the five cases. Three out of five cases had gram negative sepsis in form of E.coli, (journal of tropical medicine, August 2009) and all the three patients died. The delay in diagnosis has high mortality, which happened in respect of this patient because on 23.08.12 patient did not get admitted and signed LAMA by her husband and when she got admitted attendants were not willing for any investigation with which disease could be diagnosed early,  no wrong treatment was given to the patient. There were no extra charges taken from the patient.

3.4.  In reference to allegations of complainant in paragraph 20 of the complaint [already mentioned in sub-paragraph 2.6 above], the OPs respond as-

 (a). Patient was attended in a proper way, that’s why a rare diagnosis could be made.

(b). The patient’s attendants were explained about patient’s poor condition. Patient did not suffer from any side effect of the medicines during treatment. Treatment was not aimless and reason for delay in diagnosis has already been exhibited.

(c). The patient was suffering from disseminated strongyloidiasis. Disseminated strongyloidiasis is often associated with enteric bacterial infections. It has been hypothesized that intestinal luminal bacteria may accompany the parasite during its transmutably migration across the intestinal wall. The patient's blood culture was positive for E.Coli, for which she was started on inj meropenam which was given to the patient.

(d). Patient was seen by cardiologist.  He did not advice any ECG or ECHO. Hypokalemia causes conduction defects, but it does not cause heart damage and treatment of hypokalemia is potassium supplementation, which was given to the patient.

(e). Patient suffered from nephritic syndrome. I/v contrast can cause renal failure, but prior to doing CT scan, serum creatinine was 0.39 mg/dl. So patient was having normal renal function. Post CT scan patient’s urine output was good, but patient deteriorated on 07.09.2012 due to disseminated strongyloidiasis and gram negative septicemia Patient was not on any nephrotoxic drug. Patient renal function was normal prior to CT scan, so no dialysis was required. After discussing with gastroenterologist, CT scan was performed. Since intra-abdominal pathology is best described by CT abdomen with contrast rather than USG and MRI, so best investigation was performed.

(f). Patient was already on statin, which was stopped on 05.09.2012 as due to poor oral intake. Skin lesion was not related to cholesterol remobilization, so statin was not started.

(g). Patient was not treated badly. Patient was suffering from a rare problem. Few cases were reported from India (already mentioned in previous points).

(h). Electrolytes were managed in the best manner. Steroid was given in low dose as maintenance dose (inj effcolin 100), because sudden withdrawal of steroid cannot be done. Patient hemoglobin was 12.5 gm/dl on 28/8/2012, 10.9 gm/dl, and 8.3 gm/dl on 7/9/2012, no need of blood transfusion on these reports. 70000 platelets are not an indication for platelet transfusion.

(i). Patient was shifted in ICU as per condition of the patient, (as already mentioned).

(j). The dead body was handed to attendants as per hospital protocol, in a dignified manner.

The patient was suffering from nephritic syndrome with normal renal function. She deteriorated because of disseminated strongyloidiasis and septicemia and DIC, not because of CT with contrast. Skin lesion already described was suggestive of vasculitis, which has nothing to do with contrast and may be related to disseminated strongyliodiasis. Investigations sent from ICU were suggestive of severe sepsis with coagulopathy with DIC with underlying gastrointestinal bleed. Her hemoglobin was 4.7 gm/dl, TLC dramatically low just 300/cumm and platelet were 15000/cumm. Feature of marked pancytopenia. Blood culture was positive for Ecoli. PT was 71.9 sec and APPT was more than 250 sec, which suggest severely deranged bleeding parameters. There is no negligence of the treating doctors or of hospital authorities. In fact rare diagnosis was made by OP1, which has high mortality. There is neither wrong treatment, nor any negligence done  to the said patient.  The complaint is liable to be dismissed.

4.  (Replication of complainant) - The complainant filed detailed replication by re-affirming the complaint correct by adding explanation to explain the complaint and to deny the allegations of written statement.  The tests and investigation between 4.9.12 to 8.9.12 were in fact maltreatment to the patient, there no duodenal biopsy done on 7.9.2012 to claim that OPs diagnosed of  strongyloides being historical surprise. There was joint treatment of various ailments, which put the patient to excessive doses of medicine. The OPs are justifying the death of complainant's wife on wrong deeds and reasons.  The OPs are also trying to drag the matter back to 23.8.2012 to pled LAMA to shield their wrongs and lapses but it would not help them.  There was lack of coordinated efforts and collective approach in diagnose of proper ailment and its proper treatment, as they were just interested in their fees.  It is detailed replication being replica of complaint, some of the expression against OPs, in the replication, are improperly worded, it could be avoided by the complainant, the same are not mentioned in this paragraph.

5.1. (Evidence)- In order to establish the case, the complainant led his evidence by filing his detailed affidavit coupled with the documentary record filed with the complaint, inclusive of medical literature.  The complainant also led evidence by filing affidavit of his son-in-law Shri Gaurishankar Jha, to establish certain facts of treatment of patient during his presence and other events happened of over-writing the medical record by OP3 that too during his presence.

5.2. The OP1 led evidence by filing affidavit of  Dr. Sunita Sunda. Medical Superintendent, which is replica of written statement with record. OP2 Dr. D.S. Rana, Chairman, Department of Nephrology of OP1 and OP3 Dr Anurag Gupta, Consultant, Department of Nephrology of OP1 also filed their respective affidavits, which are on the lines of affidavit of OP1 besides details of their respective profile.  To say, the affidavits of all the OPs are identical to their written statement.

5.3.1.   (Objections to medical expert opinion by the complainant) - Since, an expert medical opinion was sought from the Medical Board. The medial opinion was also received, however, the complainant has objections and he filed  such objections in the form of rejoinder that the opinion rendered is in stereotype and superficial manner without forwarding the reasons or analysis, for coming to such conclusions via a vis the factual matrix & tampering of record was not discussed or opined.  The opinion is not a final evidence to be accepted as it is and it is not binding. The complainant derives reasons, while relying upon - (i) Ramesh Chandra Agrawal vs Regency Hospital Ltd. & Ors [Civil Appeal Nos. 5991 of 2002], (ii) State of Maharashtra vs Damu s/o Gopinath Shinde and others, AIR 2000 SC 1691 (iii) Malay Kumar Ganguly vs Dr. Sukumar Mukherjee [Criminal Appeal no. 1191-1194 of 2005 along with Civil Appeal no. 1727 of 2007] and (iv) The State (Delhi Administration) vs Pali Ram [AIR 1979 SC 14].

5.3.2 (Reply of OPs) - The OPs opposed the objections of the complainant that Medical Board was constituted to render independent opinion and they had considered all material of complaint as well as medical record, then opinion was rendered that the doctor were qualified to treat the patient,  no negligence was found since the OPs had followed all protocol of treatment and the patient was given the best  treatment.  The Consumer Fora had sought just opinion, that has been rendered by the Board. The objections of complainant do not sustain and the same cannot be accepted. The opinion is independent and it is to be considered in favour of OPs.

6.1 (Final hearing)-  At this juncture, the complainant filed detailed written arguments by spitting into various headings followed by oral submissions as well  referring the plea of OPs to high-light that allegations of the complaint has been proved and also deriving reasons from the general medical literature on various diseases including relating to disease strongyloidiasis. There is negligence, bad diagnosis, wrong line treatment and mismanagement on the part of OPs, which result into her casualty. Moreover, a chart is also prepared to show that there were certain noting added/written subsequently in the record by OP3 to cover-up flaws of OPs in order to justify as if the death of patient was not because of fault or negligence of OPs.

6.2. Similarly, OPs also filed their detailed written arguments, which is bled of their reply and evidence, following by oral submissions, while opposing the complaint and claims of complainant.  The OPs also relies upon Sant Parmanand Hospital Vs Dr. J Maheshwari (FA no.716/2007 dod 4.9.2019 by Hon'ble State Commission, Delhi), when prescribed procedure and protocols for administration of treatment are followed,  doctors cannot be held liable, when they are qualified and skilled professionals in their medical profession.

7.1 (Findings)-  The contentions of both the sides are considered, keeping in view the  material on record, which also comprises documentary record besides statutory provisions of law  & case law presented. Since the plea of complainant is of medical negligence etc. against Hospital/OP1 and its treating doctors/OP2 & OP3 but OPs' case is of there is no such alleged medical negligence, etc., on their parts.

7.2. Thus, to determine whether or not there is medical negligence etc, it is appropriate at this stage to first refer a precedent on the point of medical negligence, test, guidelines and scale to be applied to determine it, ethics involved and so on. It is laid down in precedent 'Vinod Jain Vs Santokba Durlabhji Memorial Hospital AIR 2019 SC 1143 [paras, 8,  9 and 12; in which the previous precedent Kusum Sharma & others Vs Batra Hospital & Medical Research Centre & ors AIR 2010 SC 1050 is also referred with its relevant paragraphs are Para 22 & 89] -

[Para 8]  "22. Negligence. -Duties owed to patient. A person who holds himself out as ready to give medical advice or treatment impliedly undertakes that he is possessed of skill and knowledge for the purpose. Such à person, whether he is a registered medical practitioner or not, who is consulted by a patient, owes him certain duties, namely, a duty of care in deciding whether to undertake the case; a duty of care in deciding what treatment to give; and a duty of care in his administration of that treatment. A breach of any of these duties will support an action for negligence by the patient"

[para 9]. A fundamental aspect, which has to be kept in mind is that a doctor cannot be said to be negligent if he is acting in accordance with a practice accepted as proper by a reasonable body of medical men skilled in that particular art, merely because there is a body of such opinion that takes a contrary view (Bolam v. Friem Hospital Management Committee -1957 1WLR 582). In the same opinion, it was emphasised that the test of negligence cannot be the test of the man on the top of a Clapham omnibus. In cases of medical negligence, where a special skill or competence is attributed to a doctor, a doctor need not possess the highest expert skill, at the risk of being found negligent, and it would suffice if he exercises the ordinary skill of an ordinary competent man exercising that particular art.

A situation, thus, cannot be countenanced, which would be a dis-service to the community at large, by making doctors think more of their own safety than of the good of their patients.

[12]. In para 89 of the judgment in Kusum Sharma & Ors. the test had been laid down as under:

"89. On scrutiny of the leading cases of medical negligence both in our country and other countries specially the United Kingdom, some basic principles emerge in dealing with the cases of medical negligence. While deciding whether the medical professional is guilty of medical negligence following well known principles must be kept in view:

I. Negligence is the breach of a duty exercised by omission to do something which a reasonable man, guided by those considerations which ordinarily regulate the conduct of human affairs, would do, or doing something which a prudent and reasonable man would not do.

II. Negligence is an essential ingredient of the offence. The negligence to be established by the prosecution must be culpable or gross and not the negligence merely based upon an error of judgment.

III. The medical professional is expected to bring a reasonable degree of skill and knowledge and must exercise a reasonable degree of care. Neither the very highest nor a very low degree of care and competence judged in the light of the particular circumstances of each case is what the law requires.

IV. A medical practitioner would be liable only where his conduct fell below that of the standard so far reasonably competent practitioner in his field.

V. In the realm of diagnosis and treatment there is scope for genuine difference of opinion and one professional doctor is clearly not negligent merely because his conclusion differs from that of other professional doctor.

VI. The medical professional is often called upon to adopt a procedure which involves higher element of risk, but which he honestly believes as providing greater chances of success for the patient rather than a procedure involving lesser risk but higher chances of failure. Just because a professional looking to the gravity of illness has taken higher element of risk to redeem the patient out of his/her suffering which did not yield the desired result may not amount to negligence.

VII. Negligence cannot be attributed to a doctor so long as he performs his duties with reasonable skill and competence. Merely because the doctor chooses one course of action in preference to the other one avail-able, he would not be liable if the course of action chosen by him was acceptable to the medical profession.

VIII. It would not be conducive to the efficiency of the medical profession if no doctor could administer medicine without a halter round his neck.

IX. It is our bounden duty and obligation of the civil society to ensure that the medical professionals are not unnecessarily harassed or humiliated so that they can perform their professional duties without fear and apprehension.

X. The medical practitioners at times also have to be saved from such a class of complainants who use criminal process as a tool for pressurizing the medical professionals/ hospitals particularly private hospitals or clinics for extracting uncalled for compensation. The malicious proceedings deserve to be discarded against the medical practitioners.

XI. The medical professionals are entitled to get protection so long as they perform their duties with reasonable skill and competence and in the interest of the patients. The interest and welfare of the patients have to be paramount for the medical professional.

            It is relevant to mention since certain tests, guidelines and rule has been laid down in precedents Vinod Jain Vs Santokba Durlabhji Memorial Hospital AIR 2019 SC 1143 [paras, 8 9 and 12] & Kusum Sharma & others Vs Batra Hospital & Medical Research Centre & ors AIR 2010 SC 1050, therefore, from that point of view, certain duties are prescribed in the medical profession, they are (i) a duty of care in deciding whether to undertake the case; (ii) a duty of care in deciding what treatment  is to be given and (iii) a duty of care in administration of that treatment.  On failure to observe them, it will be case of medical negligence. Therefore, it would be appropriate to take the feature of this case one by one from that point of view.

7.3.  With these background, now stage has been reached to discuss and analyse the case of parties. However,  before proceedings further in the matter, some relevant observation needs to be recorded.  

       Firstly- on the one side the complainant and his son-in-law are only witnesses to the case. The complainant asserts that he had taken advices or opinion of medical experts at his level, however, no evidence of such person has been led.  On the other side, OP1, OP2 and OP3, [being party to complaint], led their own evidence; there is also no other independent witness on behalf of OPs. 

        Secondly - The complainant as well as OPs have relied upon general literature on diseases, whereas the present Commission has to consider the case to specific and subjective to the patient. In addition, OPs also refer some literature of Journals to fortify its stands, however, it appears the same has been referred as academics, otherwise those journals have not been proved.

            Thirdly, on plain reading of materials, at many instances,  the complainant opines as if some acts ought to have been done in a particular manner, otherwise to acts done by the OPs, the complainant is pressing those aspect as if an expert, however, he has not proved himself to be medical professional or expert. Further, the complainant himself adds that there are his personal observation, however, it cannot be considered conclusive evidence or opinion. On the other side, the OPs have justification that treatment was given as per norms and protocol etc.  However,  as per record not only there is original record of treatment is available but also clinical chart of ward and Nurses note of patient, which will be considered for appreciating the case of parties.

            Fourthly,  the medical Board has given expert opinion [already referred in sub-paragraph 1.4 above],  the opinion received is not accompanying with reasons for such opinion, that is why it has been objected by the complainant. But, OPs refers them to consider it, that an independent body has rendered the opinion, nothing is to be searched beyond but suggested by complainant.  However, the opinion is not a conclusive in itself, therefore, material on record will be assessed, which will itself determine whether to accept or decline the report as it is.

            Fifthly, there are many other rival contention, like CT scan was performed by the receptionist- a layman himself instead of any radiologist, as observed by the complainant

or the dead body of patient was handed over without dignity. But the plea of other side is that CT scan and its report was by qualified/professional technician under doctor. There is no remarks, as alleged by complainant,  while receiving the dead body by relative of deceased. There is also grievances that OP2 was consultant in OPD for patient, the patient was also admitted on his advice, however, he was not regular to visit and monitor the patient during her hospitalisation, the patient was managed by other/junior doctor. The other side's plea is that patient was under the best care and treatment of team of doctors, OP2 has been visiting vis  a vis he was kept on informed on daily basis besides OP3 and references to other doctors.  Since,  this complaint is under the consumer law and it is being dealt as per summary procedure, therefore, the material/relevant issues will be determined, instead of such issues of blames or counter-blames. Now the core issues are being taken.

8.1.  Since the Smt. Saroj Devi was outdoor patient of OP2 under OP1 and later she was indoor patient till she expired in the hospital. The following is chorology of diagnosis and treatment rendered by OPs to the said patient as per record of OPD and IPD papers :-

(i) [Diagnosis of  HTN & DM, & suspected ?FSGS/ Nephritic syndrome during OPD] - The first document proved is  computerized OPD card of 6.5.2012 prepared by OP2, she was diagnosed of HTN & DM  when she consulted OP2 with complain of edema in feet (with recording of history of kala-zar  she had in 1987),. She was advised accordingly alongwith advices of review.  There are total 8 such OPD  cards, in which she is diagnosed of HTN & DM from 09.05.2012 to 11.8.2012 (but in two OPD cards of  11.7.2012 and  11.8.2012 she was  suspected by recording ?FSGS/ Nephritic syndrome.

             On 23,8.2012, the complainant was advised for hospitalisation of patient but the complainant get the patient released at his discretion and advised potential risks.

(ii)  Smt. Saroj Devi had abdominal distention on 27.8.2012. she was admitted in the hospital of OP1 on 28.8.2012 and she was provisionally diagnosed of Nephritic syndrome (NS).  There had been regular and routine tests, from time to time, and she was being treated so.  The investigations and prescription on  record are under heading of  diagnosis of  Nephritic syndrome throughout.

(iii)   The patient Saroj Devi remained indoor patient for  12 days  from 28.8.2012 till she died on 8.9.2012 in the hospital of OP1 under OP2 and OP3.  The following were the diagnosis diagnosis on the basis of regular tests, investigation and its evaluations from time to time :-

(a) -  case of infection of  duodenum

(b) - case of suffering from tuberculosis

(c) - case of parasitic infection and vasculitis

(d) - case of  sclerosis

(e) -  case of invasive strongyloidiasis [this diagnosis is objected by complainant for want of any duodenitis bioscopy].

(iv)  The patient had cardiac arrests  and she died on 8.9.2012, the OP1 issued certificate with cause of death - septic shock with duodenitis with invasive strongyloidiasis with LRT with dys-electrolytemina.

8.2   Since the complainant has  grievances of medical negligence, bad diagnosis, wrong line treatment and mismanagement on the part of OPs vis a vis there are guidelines or   certain duties are prescribed in the medical profession, which are (i) a duty of care in deciding whether to undertake the case; (ii) a duty of care in deciding what treatment  is to be given and (iii) a duty of care in administration of that treatment. The case of parties will be discussed under these guidelines one by one.

9.   Firstly, issue of duty of care in deciding whether to undertake the case?  The first issue is whether the OPs had taken proper care to under the case.  Since the patient was already under treatment of OP2 of OP1 from May 2012 and the patient was diagnosed of  of  HTN & DM, & suspected ?FSGS/ Nephritic syndrome, with appropriate history of medication as well as that patient had kala-zar in 1987.  She had been under continuous treatment, there was also no complete improvements in recovery.  Later, when she had complained of edema in feet as well as abdominal distension, then she was admitted as indoor patient. The OPD card of 23.8.2012 also mentions name of OP3.  Thus, so  far the task of OPs to undertake case of Smt. Saroj Devi is concerned as OPD  and IPD, there is no negligence on their part as OPs are in the medical field and services, the OP2 and OP3  are Consultant, Nephrology. The first component stand determined accordingly.

10.1 Secondly, the issue of duty of care in deciding what treatment is to be given?   This issue involves component of diagnosis and correspondingly the treatment to be given. When the patient was initially admitted, she was diagnosed of electrolytes imbalance with case of HTN & DM and case of nephritic syndrome. Since, the patient was indoor patient, there was regular monitoring as well as she was being attended, however, both the sides have rival plea.

10.2. Accordingly to complainant the OPs not only failed to diagnose the disease properly but also improper treatment was given, which started from balancing electrolytes to infection, then tuberculosis, sclerosis. She was never diagnose to be suffering from strongyloidisis nor treated for it but falsely claimed by the OPs to be main cause for her death. Since there was no proper diagnosis at all, there was wrong line of treatment rendered and the attending doctors had given wrong medicine that too in excessive quantity.

            Whereas the OPs have opposed all these contention,  that neither there was wrong diagnose nor negligence nor wrong line of treatment.  The chronology of events are crystal clear that the patient was under constant monitoring by the team of doctors including OP2 and OP3,  there were regular check-up, investigations and its evaluation and the patient was accordingly prescribed diet, medicine and other prescription.  When, the patient is being monitored constantly and also being attended specialists vis a vis appropriate medication was being done, how it could be imputed medical negligence. There were also reference to other departments and that was considered, which suggest that all attention were being given to the patient. There is no medical negligence at all.  [The OPs refers the record of written statement to show day to day basis evaluation, prescription etc, it has already been mentioned in sub-paragraph 3.2. above].  The OPs have considered all the material emerged from the analysis and evaluation of reports, then treatment was given, it cannot be faulted nor it infers medical negligence.

10.3.     By taking into account all these circumstances and material on record, the following conclusions are drawn -

(i)  It is already explained that the patient was admitted as indoor patient on 24.8.2012 and on 4.9.2012, there occasion for discharge of patient. At that moment, the discharge summary was also prepared but patient was not discharged or get discharged and treatment continued. The discharge summary of 4.9.2012 prepared shows that patient was diagnosed of (1) Nephritic syndrome (FSGS),  (2) Hypothyroidism, (3) Hypertension, (4)  P/W Hyponatremia, (5) Hypokalemia and (6) constipation.

            There are corresponding progress notes and investigation orders by the doctors. Moreover, clinical chart-ward with nurses notes are there, showing compliances of those investigation order, prescriptions etc.

(ii)   On 5.9.2012 the patient was  diagnosed of  infection of duodenum [duodenitis,  infective, inflammatory]. The medicine were also prescribed, which were followed as shown in clinical chart of ward.

 (iii)  On 6.9.2012, she was also diagnosed by the doctors that patient is suffering from TB and anti-TB tablet was started (there was already also receipt of CT reports of thorax and whole abdomen and Upper GI endoscopy). Chest medicine was prescribed on 6.9.2012 including ATT.

(iv)  It is admitted case of OPs that after taking the consent from family, UGIE was done on 04.09.2012, which was suggestive of duodenitis but still diagnosis was unclear.

(v) On 7.9.2012 patient was started giving medicine 'Ivermectine', in place of earlier medicine.  

(vii) The OPs claims that on 7.9.2012 duodenitis bioscopy was conducted on the patient and OPs discovered of rare disease strongyloidisis in the patient and treatment was started. Whereas there is no investigation order for duodenal biopsy nor noting in the clinical chart-ward/nurse notes to get done duodenal biopsy of patient.  Further, there is no such duodenal biopsy report of 7.9.2012 filed in support of written statement or in support of affidavit of evidence. Lastly, there is no proof of bill charged from complainant of duodenal biopsy on 7.9.2012.  When there was no duodenal biopsy done on 7.9.2012, how could there be duodenal biopsy of 7.9.2012? Further, for want of duodenal biopsy report, then how conclusions were drawn for discovery of rare disease?  The OPs are substituting the medical literature for drawing such inference, but even for that there should be first duodenal biopsy report.

            However, there is another UGI endoscopy report dated 4.7.2012, but the OPs are referring them for some other purposes prior to 7.9.2012. The OPs are referring another report of 7.9.2012 of duodenal biopsy, which has not been proved by the OPs.

(viii) When there is no duodenal biopsy report dated 7.9.2012, then how cardiology department is referring duodenal  bioscopy report for suggesting rare disease?

(ix) Then patient was shifted to ICU and she had cardiac arrest and she died on 8.9.2012.

10.4. The conclusion from paragraph 10.3 reveals that patient was admitted with complain of abdominal pain and edema in feet and there was treatment for electrolyte imbalance. But when complainant had either problem of fever or loss of appetitite or pains in the limbs or so on, she was put to further tests and examination.  The material on record proves she was diagnosed for different diseases on the basis of symptoms or evaluation of reports, accordingly treatment was given by way of medicine, even there is not only change of medicines but also medicine was also stopped when a particular disease was not there.  The medicine of TB was started but it was stopped, it means the OPs were confirmed later that it is not case of TB. Similarly, opinion was also formed about sclerosis and medication was started. It infers that the things were rolling one after the other to actual decipher the disease actually patient was suffering from.  Although, change of medicine may be part of strategy but inclusion of one after the other means that diagnose was in swinging situation. To say, the OP1 and its doctors, including OP2 and OP3 could not confirm actual diagnose of disease vis a vis treatment was started or stopped for one disease was because of that reason. The OPs also admits that on receipt of UGI endoscopy, diagnosis was unclear to them.

10.5.  The patient was already indoor from 28.8.2012,  endoscopy and CT scan were already done on 4.9.2012 and 5.9.2012, but it was 7.9.2012, when the OPs could form opinion to prescribe 'Invermectine' when patient had developed red rashes on her thighs and legs.  Further on the same very day, it was recorded that there was septic shock at 8 pm; septicemia at 7:45pm. OPs also  claim that patient was suffering from rare disease of invasive strongyloidiasis by referring duodenal bioscopy report of 7.9.2012 but that duodenitis bioscopy was neither done to patient nor it was proved. Thence, episode of cardiac arrest too place and patient died.   

10.6. It is manifest from the circumstances and evidence of parties,  that OPs could not diagnose the disease  but treatment was being rendered  on symptoms or complications arising during the treatment.  Since, there was no confirmed diagnosis, that is why line of treatment varied accordingly.  [However, the sequence of timing and care, timing of preparing the record will further be discussed in paragraph 12 (Ibid.)].

10.7. In the death summary there are two cause of deaths viz (a) immediate cause of septic shock with duodenitis with invasive strongyloidiasis with LRTI with dyselectrolytemina and (b) antecedent cause  of  nephritic syndrome.  As per record, the patient has been under treatment from May 2012 for nephritic syndrome and she was diagnosed of  infection of duodenum on 5.9.2012 but  septic shock and other current causes was of 8.9.2012.  Disease strongyloidisis was stated to be discovered after duodenitis bioscopy of 7.9.202 and it is being linked to kalazar, however,  kalazar was already known to OPs, which find mentioned in the first OPD card of May, 2012 but duodenitis bioscopy has not been proved by OPs .

10.8. So, OPs failed in  its duty of care in deciding what treatment is to be given after proper diagnosis of disease vis a vis the complainant has succeeded to prove the case of medical negligence against the OPs.

11.1. Thirdly, the issue of duty of care in administration of that treatment is being taken. The complainant has grievances that  there is lack of proper management and promptness to attend the patient and to do needful evaluation in time vis a vis requisite steps were not taken promptly despite the requirement.  For CT scan I.V. contrast was used instead of using oral contrast for CT scan. As per UGI endoscopy report, she had been suffering from infection of the duodenum. but a simple stool test was not done for investigating the duodenum infection and the OPs had no answer. Later-on 06.09.2012, they advised stool test, which was sent for examination the next morning but till then it was of no use being belated. It was advised that the patient was suffering from tuberculosis and anti-tuberculosis drugs were started. But on the very next day, they told that the patient was suffering from parasitic infection. The anti-tuberculosis drugs were stopped  but  treatment for parasite was started.  The condition of patient was not improving. Then OPs told the complainant that patient was suffering from sclerosis.  when on 07.09.2012, the patient developed red rashes on her thighs and legs, immediately doctors were informed. Then another medicine Ivermectine was prescribed in place of previous tab. Nizonide. The patient was not shifted to ICU in time on 7.9.2012 for the reasons known to them despite investigation order but subsequently on 8.9.2012 she was virtually dead but to save themselves from the complainant’s antagonism and just not show instance of death in the ward itself then her dead body was shifted to ICU.

            However, all these contentions of the complainant are denied by the OPs, that there is no substance therein on the basis of medical record and treatment met out to the patient. There were visits and examination of doctors of all the department to meet the need of patient, she was attended throughout and appropriate treatment was given as per protocol.  The requirement IV contrast was applied because of more accuracy and better   result and it has no bearing to the cause of sickness or death of patient.  There was no reason to shift the patient to ICU until required so, since all the doctors including OP2 and OP3 were monitoring the patient closely being a team work and there was constant attention. There was proper management as well as prompt to the treatment.  However, initially the complainant was not cooperative for GI endoscopy and delay is contributable to the complainant.

11.2.  It is apparent that parties are putting blame on each other either on the point of promptness or want of cooperation or refusal for upper GI endoscopy.  It is not the case of parties that GI endoscopy was advised immediately on the admission of patient on 28.08.2012.  There are clinical progress reports as well as nurse  notes-ward. The UGI endoscopy was done on 4.9.2012, the clinic chart ward/nurse notes also shows that initially UGI endoscopy was refused by attendant of the patient. It was done, when the patient was not got discharged and patient continued as IPD.

            The treating doctors forms the opinion to follow the procedure and in case one of the options for procedure is followed than it does not mean for want of following the other option would be flaw on the part of treating doctor. Thus, when doctor took decision for IV contract for CT scan, in place of oral contract, it does not mean the investigation was not proper.  However, simple stool test was advised but it was not carried by OPs, there is  definitely flaw on the part of OPs, despite it was advised in the prescriptions as well as it find mentioned in the clinical chart.

            So far GI endoscopy is concerned, it needs to refer the investigation Orders. On 30.8.2012/at 4pm, on the left side of advices (over-leaf of page 10 of original), there is 'plan for endoscopy'.  However, in the investigation of 31.8.2012 at 10am, there is no such instruction for endoscopy.  But at 4 pm/31.8.2012 there is advise for endoscopy and it is also mentioned that it is refused by attendant of patient. In the clinical chart of ward, UGI endoscopy is mentioned but no such refusal. On 1.9.2012 under column of advices, UGI endoscopy is advised for Monday (i.e. 3.9.2012) but on 2.9.2012 it was recorded 'refusal' by attendant.  On 2.9.2012, it was recorded on left side of orders as advices upper GI endoscopy but refused by attendant [In clinical chart it mentions endoscopy for Monday was noted down but no refusal is mentioned, however, the refusal find mentioned in the chart of 3.9.2012].  Then, discharge was plan but it was dropped. There was GI endoscopy on 4.9.2012.  

            On 7.9.2012/12:10pm, there was important instructions for cholesterol investigation likely and it was advised to start statin + urgent cardiology referral.  Then other doctors on reference examined and opined ?vasculitis and skin biopsy was taken, other treatment to continue [steroid 40 mg was suggested in different ink and writing). There was urgent advise on 7.9.2012 for ICU, however, the patient was not shifted there on the advice of other doctor. There is conflicting opinion inter-se treating doctors and other to shift in ICU. What factor of TB was influencing or else, it not known?  Subsequently,  when septicemia happened, patient was shifted to ICU on 8.9.2012 and put on ventilation.  Another conflicting fact is that urgent cardiology referral and starting “statin +” was advised on 07.09.2012 by the attending doctor but that was ignored by the OPs. Earlier, on 4.9.2012 she was provided with the central line system in the ward itself as against in the ICU as advised by the attending doctor for conveniently administering drugs. The reasons are not made known. This also shows many lapses happened in taking care of the patient.

12.1   The complainant has also grievances of tempering with the record, because of several entries in separate place, on the instructions/progress notes, for which separate chart has been prepared, which is denied by the OPs.  While making plain reading of entire record, it appears that some of page ought to be numbered in front, have been kept overleaf, it lose the symmetry.  Some of the pages are not properly put in serial and because of it also loose continuity but by restructuring them properly, the symmetry is resumed. However, in some sheets timings and dates are mentioned but at other places, it is not mentioned.

            On 30.8.12/4pm, there is plan for endoscopy but on next day 31.8.12/10am, there is no such advices, however, at 4pm/31.8.12 there was UGI endoscopy as well as on left side of advice, it is recorded as if it is refused by attendant. In the sheets of 1.9.2012 and  2.9.2012, the advices for endoscopy is on separate margin as well as refusal is also immediately its underneath.

            On 7.9.2012/at 11:15, there was reference to Dr. Sadwik, who responded to reference by advising Tab. Invermectin 12mg/OD, then there is another prescription of Tab. Invermectin 200mg/daily x5days & Tab. Invermectin 12mg/dailyx5days [which are mentioned in the clinic chart-ward with over-writing/cuttings]. Then again Tab. Invemeetol 9mg/dailyx2week is mentioned below invasion strongyloidsis [without any date above the next portion of 7.9.2012/7:45pm), however, this prescription is not mentioned in clinic chart-ward of nurse notes. Lipid profile is also advised at 7:45pm, which has been added in the clinic chart-ward.  The condition of patient was poor, but controversy is that attendant was informed or not of it. At 8pm,  septic shock ?DIC was also recorded.  Thence it also record by Cardiology reference that patient is suspected cholesterol  embolic, lipid profile was advised.

12.2. The patient had kalazar in 1987 was very much in the knowledge of OPs and the patient was found affected by infection after her investigations and tests.  However, OPs claim that they diagnosed a rare disease of strongyloidiasis, but what appears is that  after gathering all information, it was very much clear to OP2 and OP3 that patient was suffering from and affected by infection, however, preliminary tests of stool were not attempted in the earlier known background. Then there was upper GI endoscopy and CT scan, the OPs had further information.  The OPs claims that they arrived to final diagnosis of strongyloidiasis, if so, it is some hours before she was seriously affected and died.    However, this is claimed on the basis of duodenal biopsy on 7.9.2012 but there is no instructions for duodenal biopsy by the doctors in the progress notes nor such instructions were noted by nurses in clinical chart for compliances, thus OPs could not prove this vital fact. Moreover, further notes/opinion of OPs that because of duodenal biopsy of 7.9.2012 there was suggestive of parasitic infestation compatible with strongyloidiasis, which was a histological surprise is appearing to be self-serving defence of OPs, while just mentioning reference of journal, to say the present patient was suffering from disseminatination strongyloidiasis with gram negative septicemia.

13.1 In view of detailed discussion, analysis and conclusions in paragraphs 10,11 and 12, it is held that the complainant has proved the circumstances of complainant against OPs. The expert medical opinion is not accepted.

13.2. The complainant has also sought compensation of Rs.18,20,000/- against OPs. By considering totality of proved circumstances against OPs as concluded in aforementioned paragraphs, including medical expenses incurred, medical negligence etc. a lump-sum compensation of Rs 10,00,000/- is allowed in favour of complainant and against OPs to pay the same jointly and severally.  The cost of litigation is also determined as Rs.25,000/-in his favour and against the OPs.

13.3   Accordingly, the complaint is allowed in favour of complainant and against the OP1, OP2 and OP3 to pay jointly and/or severally compensation of Rs.10,00,000/- besides costs of Rs.25,000/- to complainant.  OPs are also directed to pay the amount within 30 days from the date of receipt of this order. In case amount is not paid within 30 days from the date of receipt of order, then amount of Rs.10,00,000/- will be payable with interest to be at the rate of 6% pa from the date of complaint till realisation of amount.

14.  Announced on this 20th day of December 2023 [अग्रहायण 29, साका 1945].

15. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances, besides to upload on the website of this Commission.

                                                                                                             [Inder Jeet Singh]

                                                                                                                        President

                                                                                                                                                                                                                                                                                        [Shahina]                                        

                                                                                                               Member (Female)