Case Study - Failure to conduct Pre-Operative Test amounts to
Medical Negligence
Amount of Compensation - Twelve Lakhs
By Mohit Popli
Mr. Neeraj Amarnath Dora Versus Shri Nandan
Hospital Sarsiji & Ors
National Consumer Disputes Redressal
Commission
Original Petition No. 187 Of 1999
Decided On: 17th September, 2013
Negligence: Opposite parties were
neither prepared nor equipped to handle the nature of surgery. No pre-operative tests like MRI or Ultra
Sound of the abdomen were done. No arrangement for
blood was made. Even blood grouping was done after the emergency had already
arisen.
Intro/Fact:
Complainant Neeraj Amarnath Dora has filed this Consumer Complaint
seeking compensation of Rs.1,47,85,129 from Nandan Hospital and two doctors for
the death of his wife, Shalu Neeraj Dora. The deceased, a 31 year old woman,
was married in 1989 and had a son in 1990. The child died in 1997. In April
1999 she consulted the OPs and was diagnosed to be a case of secondary
infertility. On 15.4.1999, she was admitted in Shri Nandan Hospital hospital
by Dr. Nimish R. Shelat for diagnostic laparoscopy to determine the
exact reason and location of the infertility.
The Complaint petition describes details of what happened. Feeling
concerned about the condition of his wife, the complainant entered the
Operation theatre and found that—
“the floor around the operation
table had turned red with the blood spilled from the body of his wife. The
abdomen of late Shalu Neeraj Dora was cut open and the Dr. Nimish R. Shelat had
both his hands inside the cut as if he was holding something. Then
the Dr. Nimish R. Shelat took out his right hand and took a cotton gauze from
one of the nurses and placed the cotton gauze inside the body of the
Complainant’s wife, Smt. Shalu Neeraj Dora. When the Dr. Nimish R.
Shelat had taken his right hand out of the abdomen of late Shalu Neeraj Dora
the Complainant saw blood coming out from the abdomen of his wife. The
blood was coming out with such a great
force that it made a whizzing sound as if the same was coming out of a
nozzle…………. Apparently, the Dr. Nimish R. Shelat while carrying out
laparoscopy had damaged a major blood
vessel and carried out open surgery (laparotomy) without informing the Complainant and/or obtaining the consent of
the Complainant……………….. That the Complainant was
asked by one of the nurses to bring in two bottles of Haemaccel. The
Complainant ran downstairs and called up his friend Mr. Sandeep Desai who owned
a medical store and asked him to get two bottles of hemaccel to the hospital
without wasting any time. The said friend came to the hospital with
two bottles of Haemacel at about 9.30 A.M. which were handed over to a
nurse………………. That around 9:30 A.M. the Dr. Nimish
R. Shelat came out of the Operation Theater and called the Complainant. The
Complainant was taken inside the Operation Theater and told that the Dr. Nimish
R. Shelat was able to control the bleeding and after a pause of 5-10 seconds
the Opposite Party stated that the heart had stopped and that he had called the
Cardiologist…………That one, Dr. Kazi, Cardiologist arrived at Sri Nandan Hospital
at around 10:00 A.M. and ordered for some injections and medicine which were
brought by the friends and relatives of the Complainant………. Dr. Kazi
after 30 minutes reported that the heart of late Shalu Neeraj Dora had started
working. At this stage, for the first time, complainant was asked to
procure two units of bloods…………….. It is pertinent to mention here
that the Dr. Nimish R. Shelat had been so grossly negligent that neither did he arrange any blood before the
start of the laparoscopy nor did he ask the Complainant to procure blood
till Dr. Kazi after examination of the condition of the Complainant’s wife Smt.
Shalu Neeraj Dora asked the Complainant to arrange two units of blood only at
around 10.30 A.M., whereas the Dr had by his negligence cut a major blood
vessel in the abdomen of the Complainant’s wife even before 9.15 AM allowing
draining of blood for more than one and quarter hour with great force as stated
above. The Opposite Parties were further negligent in not calling a Vascular Surgeon who
could have successfully repaired the damaged vessel. Due to the said negligence of the Opposite
Parties, the wife of the Complainant suffered a cardiac arrest…………… This
clearly shows that the Opposite Parties were grossly negligent by not taking
required steps for controlling loss of blood after negligently damaging the
major blood vessel and not providing sufficient quantity of blood to save the
life of the Complainant’s wife…………………..That thereafter Dr. Kazi stated that
since the Opposite Party No.1 hospital is not equipped with an ICU or ICCU the
patient could be transferred to a bigger hospital……………The wife of the
Complainant was thereafter transferred to Surat General Hospital in an
ambulance. The condition of the Complainant’s wife during
transportation to Surat General Hospital was very precarious and
critical”.
Another surgery was performed on the deceased at Surat General
Hospital (SGH) by DR. NIMISH R. SHELAT together with Dr Ajay Seth of SGH. After
the surgery, she was moved to the ICCU and was declared dead at 4.30.PM. The
case of the complainant is that the deceased was a healthy woman who died due
to gross negligence of the OPs.
Pleading and evidence of the complainant
Loss of Blood Admitted
As per the record, two bottles of blood transfusion was given at
Sri Nandan Hospital, followed by another six bottles at Surat General Hospital
(SGH). As to why eight bottles of blood
should require to be transfused over a period of few hours if the loss of blood
in surgery was not of high magnitude?
In the explanantory affidavit filed by Dr. N.R.Shah, it is claimed
that it was ‘significant’ but ‘not massive’. However, that affidavit
makes and indirect admission of maximum loss of blood and fluid to have
been of the order of 1 to 1.8 ltrs of blood in both hospitals. Also, for the
most part, the affidavit focuses on what happened subsequently at SGH and not
initially at the Hospital.
Expert Opinion by Three Reputed Doctors:
Dr K C Bhat, a consultant anaesthesiologist and
ICU Specialist has filed his expert opinion on behalf of the Complainant.
1.
Not
having Proper Facilities – Dr.
KC Bhat has observed that Nandan Hospital was
not equipped with infrastructure like x-ray and ultrasound machines for
preoperative tests.
2.
Support Services Were Insufficient - During three hours of surgery,
Hospital services of a Vascular Surgeon could not be arranged.
3.
Medicines Not Prescribed - He also says that if it was a case of
blood oozing from a small spurter and not of injury to a major blood vessel as
claimed by the Opposite Parties, Hemostatics like surgicel, revici, vit-k,
ethamsylates, hemocids, chromostat etc. should have been sufficient to stop the
oozing. But there is no mention of these drugs in the records of this
case.
4.
Improper use of Anesthesia - Anaesthesia was not given/maintained
in a proper manner for induction followed by relaxation, doses of 3 mg pavalon
in a patient being a 74 kgms was insufficient. If complete
hemostatics and adequate anaesthisia reversal had been achieved, then the patient
should have been extubated.
5.
The
fact that indo-tracheal tube had not been removed would mean either that the
patient was so critically ill that she tolerated the tube or she was in
reversal haemorrhagic shock. During journey to the SGH, the patient
reportedly pulled out her endo-tracheal tube. This shows that the patient was
not adequately sedated, which amounts to negligence on the part of the
doctors
Dr Dharam Chawla, Laorascopy and General Surgeon
has also given expert opinion on behalf of the Complainant.
Preoperative MRI Scan was required:
He has noted that the patient had history of previous caesarian
delivery, which indicated possibility of bad and difficult adhesion. Therefore,
preoperative MRI scan on the abdomen was required.
No Equipments:
The Hospital also did not have capnograhy equipment, which is
essential for laparoscopy procedure Without this, there could be no monitoring
of CO2 levels in the abdomen. Increased levels of blood can be
lethal.
The OP Hospital also did not have ECG machine for pre, intra and
post-operative cardiac recording. Nor was there a cardiac monitor to
record the status of the heart continuously, during the course of the
surgery. SHRI NANDAN HOSPITAL claimed to be a dedicated infertility
treatment centre of Surat City. Yet, it did not even have an ultrasound
facility.
Consequently, the collection of blood in the abdomen could be
diagnosed and managed only after the Ultrasound was done later in the afternoon
at Surat General Hospital. Further in the opinion of Dr. Chawla, if
the patient was under complete general anaesthesia as claimed, there would be
no question of vaso-vagel shock. Considering the heavy loss of
blood in this case, it would be a case of hypo-volemia.
Dr Atul Nanda, with professional background of
Residency and Fellowship in Transplant Surgery from the University of Illinois,
Chicago, has given his opinion as the third expert on behalf of the
Complainant.
Non Transfusion of Blood Products:
In his opinion, the Opposite Parties did not have expertise in
laparoscopic surgery nor was the OP Hospital equipped to handle the complications
encountered during the course of the laparoscopic surgery. The patient was
given multiple transfusions of whole blood. But, she was not transfused any
fresh frozen plasma or platelets during her resuscitation, which should be a
part of massive transfusion protocol. Non-transfusion of these blood
products could lead to deranged coagulation profile and uncontrolled bleeding.
The intra-operative cardiac arrest, in his opinion, appears to have been result
of hemorrhagic shock and blood loss during the surgery. The
ultrasound at Surat General Hospital also indicated that she was bleeding
during transfer from the OP Hospital to SGH. This shows that the broad ligament
bleeder was not properly controlled during the first surgery at OP hospital. In
the opinion of Dr Nanda, when bleeding was encountered during laparoscopy, the
laparotomy procedure should have immediately been set on.
Conclusions
Hon’ble National Commission held that “ The complainant and the Opposite Parties both agree that deceased
Shalu Dora was a perfectly healthy and normal person when she arrived at hospital
on 15.4.1999. Within a few hours, she was rushed to Surat General Hospital in a
critical state, after an open-abdomen surgery and was declared dead at 4.30 PM.
Hon’ble National Commission arrived on the following conclusions
on the question medical negligence—
i. Given her weight and height, the deceased was medically an obese
person. In such a case abdominal surgery becomes more difficult/problematic as
the operating surgeon has to cut through about four inch layer of fat. Due to
this, damage to blood vessels, in the course of laparoscopic adhesiolysis had
become a real possibility. But, the Opposite Parties did not provide for it. No arrangement for blood was made. Even
blood grouping was done after the emergency had already arisen.
ii. The deceased had history of a previous caesarean delivery. As per
expert opinion, this would indicate possible existence of difficult adhesions
in the concerned areas. On the fateful day, the Opposite Parties admittedly
performed not merely diagnostic laparoscopy but also adhesiolysis on her.
Therefore, consent of the complainant and the patient had been admittedly
obtained not just for laparoscopy but also for possible open abdominal surgery
(laparotomy). Yet, no pre-operative
tests like MRI or Ultra Sound of the abdomen were done.
iii. Evidence of the OPs shows that during transfer from OP hospital to
SGH, the patient was uncomfortable and even pulled out her endo-tracheal tube.
This would show that she was not
properly sedated, while being shifted in a state of medical emergency.
iv. In the pleadings of the Opposite Parties it is claimed that the
culprit blood vessel was identified and successfully legated. Bleeding was
successfully stopped. But, this claim is proved to be wrong in two subsequent ultrasound reports of SGH which showed that
abdominal bleeding had continued and increased. So much so, that a second
open-abdomen surgery at SGH had to be performed.
v. Expert opinion brought on behalf of the Opposite Parties itself
shows that Laparoscopic Adhesiolysis involved the attendant risk of accidental
damage to blood vessels. In the case of the deceased, with previous history of
caesarean delivery and pelvic inflammatory disease, this attendant risk should
have become more of a real possibility. But, expert opinion also shows that the
Opposite Parties were neither prepared
nor equipped to handle the nature of surgery which they eventually
performed at Sreenandan Hospital with disastrous results.
vi. Medical experts examined for the Opposite Parties have all opined
that the cardiac arrest leading to death of the patient was caused by vaso
vagal shock. But, they stop short of giving clear opinion on what could have
caused it. On the other hand, medical experts examined for the complainant have
categorically opined that it was caused by haemorrhagic shock. There is
uncontroverted evidence on record that huge loss of blood had occurred during
the surgical process at hospital. Also, the record of the anaesthetist at OP
hospital also shows that the deceased was given adequate and continuous
anaesthesia during the entire surgical procedure before transfer to SGH. In
this background, haemorrhagic shock, resulting from uncontrolled bleeding in
the course of the surgery at Sreenandan Hospital would clearly suggest itself
as the logical cause for cardiac arrest.
The six conclusions
reached, after detailed consideration in the foregoing paras make it out to be
a clear case of negligence on the part of the Hospital and the treating doctors i. Therefore,
the complaint of Mr Neeraj Amarnath Dora is
allowed. Late Shalu Dora was a housewife but she also had
independent earnings of her own. In the facts and circumstances of
the case, we are of the view that a lump sum compensation of Rupees Ten Lakhs, together with
cost of Rupees Two Lakhs, will be just and equitable award in favour of the
complainant. We therefore, award accordingly. The entire amount of
Rs.12 Lakhs shall be paid by the Opposite Parties jointly and severally within
a period of three months from the date of this order.
