Lawyer lands in vegetative state after delivery with epidural anaesthesia, Hospital told to pay Rs 50 lakh compensation

"The most important thing for administering epidural analgesia is the skill of Anaesthetist, who administers it," observed the court

Chandigarh: Accounting a Punjab based hospital and doctors liable for the deterioration of the condition of a 27-year-old patient after the administration of epidural analgesia, the Punjab State Consumer Disputes Redressal Commission has directed J.P. Hospital to pay a whooping compensation of Rs 50 lakh for cutting short the future prospects of the patient.

The patient has been allegedly brought down to a vegetative state after suffering from complications of epidural anaesthesia during childbirth.

The case relates to a practicing female lawyer in Punjab High Court. In July 2014, she came under the care of a gynaecologist associated with Mom and Me Health Care Centre for her second pregnancy. During her 39th week of pregnancy, she was taken to the doctor after experiencing severe pain. As the liquor was leaking per vagina and her blood pressure had come to 110/70 the patient was rushed to JP Hospital for painless delivery

For the purpose of her delivery was given epidural analgesia. However, it was alleged the attending anaethetist did not follow the proper procedure while administering epidural to the patient and in particular The Doctor who administered the epidural analgesia did not wait for 30 minutes after administering the epidural to see if it was properly administered and there was no complication.

It was claimed that the condition of the patient started deteriorating and emergency Lower Segment Caesarean Section (in short, “LSCS”) was done after fetal distress, which had resulted due to epidural analgesia. In fact the baby was born with absent heart beat

and respiratory effort, they alleged adding that after some time the baby recovered

As per the patient's kin, she had an acute anaphylactic reaction after epidural analgesia and had seizures with high-grade fever.

On her worsening condition, she was taken to Max Hospital where after an examination, the patient was found totally unresponsive GCS E2M2V1, Pupils B/L dilated, Chest B/L Crept. She was intubated in triage and shifted to MICU. The central line was inserted and cough reflex was present. She was sedated with Fentanyl and Midazolam Infusion. Despite best efforts, doctors at Max was unable to bring her out of the vegetative state.

The patient was later admitted to PGI Chandigarh, where her condition improved a bit and ultimately she was discharged in September 2014. However, the patient subsequently was unable to respond.

Presently, the patient does not recognize anybody as she has lost her memory totally, claimed the patient's kin, while moving a complaint with the forum alleging medical negligence and the unprofessional approach in giving the treatment by JP Hospital, the attending doctor and the Anaesthetist.

In response to this, JP hospital stated that the complaint is misconceived and unwarranted. It contended that epidural analgesia was administered by after all the options were understood, while, the doctor stated that everything was explained to the patient and her attendants and therefore, the complaint is liable to be dismissed. The opposite parties stated that after the administration of epidural analgesia, the patient had an anaphylactic reaction. The fetal heart rate dipped which necessitated C-Section. The patient was immediately taken to the operation theatre, wherein general anaesthesia was administered and Caesarean Section was conducted by by the gynaecologist...the patient was shifted to ICU...Meanwhile, the patient had seizures for which she was given injection Dilantin.

The anaesthestist in the case did not respond to court notice, neither appeared and hence the court gave the verdict ex-parte. The Gynaecoloigst on the other hand, in her reply summed up to state she is a Gynecologist and has no role to play in the entire controversy, which was an outcome of complication arose due to administration of epidural analgesia by the anaethetist.

The court referred the matter to expert committee of PGI Chandigarh, which found the following faults with the case

1. The patient was a known case of bronchial asthma and hypothyroidism. However, there is no mention of the two comorbidities in the patient in the pre-anaesthesia checkup record.
2. There is no record of the time that the epidural analgesia was given. According to the records, a call was sent to the anaesthetist for giving an epidural analgesia at 7:45 P.M. on 16.6.2014 (Page 26 reverse). At 8.00 P.M. on 16.6.2014 a call was again sent to the anaesthetist for Caesarean Section (Page 27). There is no record of the details of the procedure of epidural analgesia which includes the drugs given, their dosage and whether the test dose was given or not. There is no mention of any recording of vital signs that is Pulse Rate, Respiratory Rate and Blood Pressure immediately after the administration of epidural anaesthesia.
3. As per the records, the postoperative orders given at 9:30 P.M. on 16.6.2014 state that the patient should be dilantinized (page 19 reverse). However, the first record of seizure of the patient is at 11.00 P.M. on 16.6.2014 (page 27 reverse side). There is a discrepancy about the time of onset of seizures.
4. The patient continued to have seizures as per the records (Page 27 reverse). The patient was managed with Propofol and Midazolam without intubation and ventilatory support. In view of the condition of the patient (i.e. status epilepticus) and the drugs given the patient required ventilator support.
5. As per the records of Max Hospital, on arrival the patient was unresponsive. GCS was E2 M2 V1, pupils-bilateral dilated and fixed, chest-bilateral crepts. The patient was admitted and intubated. According to these observationsthe patient required intubation and ventilator support during transfer.

Considering the facts of the case, Justice Paramjeet Dhaliwal while referring previous cases pointed out at the Indian Medical Council (Professional, Conduct, Etiquette and Ethics) Regulations, 2002 and stated that IMC Regulations, 2002, as amended up to date, clearly stipulates the need to respect the patient’s autonomy and Doctor’s obligation to adequately inform the patient for self-determination. The first issue the forum found was with consent

In the present case opposite party No.1-Hospital has not annexed any document with regard to the consent having been taken by it from the patient or her attendants/relatives before administering the epidural analgesia. However some medical record has been annexed by opposite party No.3-Dr. Rajni Parihar along with her reply and consent form for administering anaesthesia is Ex.OP-3/4, which is neither signed by the patient nor by her attendant/relatives or anyone else on their behalf. We have put ‘??’ on the same. However, it bears the signatures of some Doctor and some witness. Such a document cannot be taken as a document of valid consent. No other document has been produced on record by the opposite parties regarding consent given by the patient or her attendants/relatives for administering epidural analgesia/surgery/treatment etc. This means that neither the patient nor her attendants/relatives were informed nor a valid consent was taken as is required to be taken as per Regulation 7.16 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002.

The court noted that all the medical record of the patient was with the hospital and the doctor but they did not produce the same on record and, as such, an adverse inference is to be drawn against opposite parties Nos.1 to 3 specifically when opposite party No.2- Anaesthetist, who had not opted to appear and was proceeded against ex parte. The court noted;

A perusal of the medical record reveals that the condition of the patient at the time of her admission in Max Hospital was worst and her senses were low. She was not understanding and not responding to a verbal response. Her mother response was extension response and eye-opening was also to pain. It means that her GCS score was much less which means that she was virtually having no senses and was not responding. There is no mention of vitals and the GCS scores of the patient by opposite parties Nos.1 to 3 in the medical record of the patient.

The court further added;

In this manner the expert report of the Medical Board constituted by the PGI, Chandigarh clearly proves that opposite parties Nos.1 to 3 are negligent in giving treatment to the patient as per the standard medical protocol.

The court proceeded to focus use of epidural in anesthesia, wherein, it highlighted in detail the usage, side effects and precautionary measures while administering epidural analgesia, stating that the most important thing for administering epidural analgesia is the skill of Anaesthetist, who administers it.

Based on the discussion and the opinion of the Medical Board of the PGI, Chandigarh, reproduced above, the court was of the view that the procedure adopted by doctors and hospital was inappropriate and questionable. Such an approach could not have been applied by opposite party No.1-Hospital and its Doctors i.e. opposite parties Nos.2 and 3. Resultantly the complainant had suffered seizures and ultimately she became unresponsive, the court added.

The court finally ordered the opposite parties to pay a gross compensation of Rs 50 lakh and held;

In the facts and circumstances of the case, coupled with aforesaid discussed evidence, opposite parties No.2 and 3 are personally liable and opposite party No.1-Hospital is vicariously liable for the deterioration of the condition of the patient after the administration of epidural analgesia and in giving post-operative treatment by opposite parties Nos.2 and 3 in opposite party No.1- Hopsital.

Also Read: Lawyer Death due to Dengue: HC directs SRN Medical College to pay Rs 25 lakhs for gross medical negligence

Based on the age of the patient, her earning propects and noting the fact that she has now become inconpacitated to take care of her two daughter, now aged 5 and 9, as well as noting the demands of the petitioners for compensation, the court ordered lump-sum compensation of Rs 50 lakh.

In view of our above discussion, this complaint is partly allowed and following directions are issued to opposite parties Nos.1 to 3:-

i) to pay ₹50,00,000/- (rupees Fifty Lakh only) in lump sum, as compensation, for the present condition of the patient;

including the expenses incurred on her treatment in opposite party No.1-Hospital, Max Hospital and PGI, Chandigarh and

the sufferings undergone by her as also for mental agony, harassment, avoidable pain, disability and suffering caused to her, along with interest at the rate of 9% per annum from the date of filing of the complaint i.e. 25.4.2016 till the date of

actual realization; and

ii) to pay ₹33,000/-towards litigation costs.