Preferring ERCP over MRCP- St Stephens Hospital told to pay Rs 4.75 Compensation

For resorting to ERCP instead of MRCP when the ultrasound was not definitive for the presence of CBD calculi., doctors at St Stephen Hospital were recently held guilty and the hospital was asked to pay a compensation of, Rs.4.75 lakhs.

Facts in Short :

1. The case goes back to January-2000. The Respondent-Complainant Mr. Zafar took his ailing mother to the St. Stephen’s Hospital, New Delhi as she was suffering from severe headache. However, the MRI Scan did not show any abnormality. After 4 days, she was again hospitalized for severe abdominal pain.

2. A tentative diagnosis of cholecystitis (gallbladder disease) was made. Ultrasound revealed biliary sludge with mild biliary dilation and showed a stone in the common bile duct. As per the advice of Dr. Lahoti, the Gastroenterologist, ERCP procedure were performed on 24.01.2000. However, the Patient immediately thereafter developed acute pancreatitis. On examination, it was found that pus was being formed in the stomach.

3. The Complainant alleged that it was due to excess quantity of laser beams thrown on the gallbladder during ERCP. The condition of the patient worsened day by day and ultimately she died on 08/03/2000 in the Hospital.

4. Hence the Complainant- the Son of the deceased filed a complaint in District Forum. The Doctors resisted the claim. They contended that pancreatitis was a known complication of ERCP and was not a result of use of laser and its decision to perform ERCP could not be faulted. Moreover, there was no laser machine at that time with the Hospital.

5. The Ld. District Forum allowed the complaint and directed the Opponent Hospital to pay Rs.1 lakh. The Ld. District Forum observed that the documents relating to ERCP suggested that one of the risk factors of ERCP was ‘inexperience of the operator’ and further held that the opponent was ‘negligent’ in that during the procedure- ducts had been injured. Pus was being formed. Pancreatitis occurred. Hence, the Appeal was filed by the Hospital.

Held :

1. The Delhi State Commission rejected the appeal. During pendency of the appeal, the Expert Committee opinion was sought from the Dean MAMC. (Maulana Azad Medical College).

2. The Expert Committee did not find the Doctors Negligent. It was also observed that the pancreatitis was a well known and unpredictable complication of ERCP and in the given case there was no use of leaser as alleged. However, it was observed that MRCP should have been preferred over ERCP since the USG abdomen report was not definitive for the presence of CBD calculi, to document the presence of CBD calculi before proceeding for the ERCP procedure. Had this been done, this ERCP and its subsequent complication could have been avoided.

3. The Commission relying upon the Expert opinion further observed that treating doctors were simply having a suspicion of stone being present in the bile duct.- In such a situation, doctor with a reasonable knowledge and a reasonable commonsense would have resorted to MRCP. No material has been placed on record by the Hospital that on the basis of mere suspicion of presence of CBD calculi, one should jump to ERCP which is having risk of complications. Court observed that Treating doctors were in a hurry to perform ERCP over MRCP. Conduct of the treating doctors thus fell below that of a reasonably competent doctor. It is not a case of difference of opinion or error of judgement.

Clearly, immediate ERCP was not required to be performed as per standard protocol.  Doctors with a reasonable knowledge should have resorted to MRCP.  It was in such circumstances that the expert opined that indication for performing ERCP was not very robust.  In other words a doctor is expected to have a reasonable degree of knowledge.  Conduct of the treating doctors fell below that of a reasonably competent doctor.  It is not a case of difference of opinion.  Treating doctors were in a hurry to perform ERCP without caring for the fact that USG abdomen report was not definitive for the presence of CBD calculi.

4. The Commission enhanced the Compensation to the tune of of Rs.4,75,000/- plus interest @ 12% p.a. from March 2000, till its realization. For calculating the compensation it relied upon various judgments of Apex Court. It a;sp relied upon the judgment of Hon. Supreme Court in the case of Nizam Institute of Medical Sciences vs. Prasanth S. Dhananka and Others, 2009 (2) CPJ 61 (SC), wherein the Supreme Court cautioned holding thus:

“… the court has to strike a balance between the inflated and unreadable demands of a victim and the equally untenable claim of the opposite party saying that nothing is payable. Sympathy for the victim does not, and should not, come in the way of making a correct assessment, but if a case is made out, the court must not be chary of awarding adequate compensation. The ‘adequate compensation’ that we speak of, must to some extent, be a rule of thumb measure, and as a balance has to be struck, it would be difficult to satisfy all the parties concerned.”

The Judgment is based on the facts of the case which occurred in the year 2000. Now after the lapse of 18 years, there must have been a great change in Medical Science including procedures like ERCP / MRCP. Nevertheless, this case tries to throw light upon the thin line of difference between the mere error of judgment and conduct of treating Doctor falling below that of a reasonably skilled Doctor.

Well, this is a state commission judgment and may come under the scanner of National Commission and lastly of Hon. Supreme Court, if it's challenged.

Thanks and regards

Adv. Rohit Erande.
Pune. ©

Case Details :

M/s. St. Stephen’s Hospital, Delhi. V/s. Masood Zafar
Case No. F.A.No.65/2006, Decided on 08/05/2018

Before :
N P KAUSHIK (Member - Judicial)

Link :
http://cms.nic.in/ncdrcusersWeb/GetJudgement.do?method=GetJudgement&caseidin=8%2F0%2FFA%2F65%2F2006&dtofhearing=2018-05-08