Negligence in Post Operative Care: Anaesthesist Suspended-Tamil Nadu

Chennai: The importance of Post-operative care was recently pointed out by the Tamil Nadu Medical Council when it suspended an Anesthesiologist of Erode based Kumarasamy Hospital, for a period of six months for leaving a patient unattended for around 15 minutes after Lower segment Cesarian section (LSCS).

Although the Council also counted lapse on the part of the Gynecologist, Dr. Sangeetha, who left the patient at the care of Anesthesiologist, Dr. Thangaraj before recovery of the patient from anesthesia, she has been left with a warning.

"The Council endorses with the views of Anethesiologist Specialist and comes to the conclusion that, the patient was probably unmonitored for 15 minutes after surgical procedure (though she was retained inside OT by the Anesthesiologist for monitoring and observation) and the unnoticed anesthesia induced hypo-tension has led to cardiac arrest and Anesthesiologist Dr. Thangaraj was negligent on his duties and not monitored the patient properly for about 15 minutes and thereby failed in his legitimate duty to attend the patient," opined the Council in its order.

While the Specialists did not find any fault with the Gynecologist's part during the operative procedure, the Council pointed out the lapse while providing post op care to the patient and noted, "Dr. Sangeetha ought not to have left the patient without full recovery from anesthesia and shifting the patient to the post operative ward/room. Had she remained with the Anaesthetist, she could have helped him to revive the patient, in the emergency situation."

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The case concerned a 22 years old patient, who was admitted to the Kumarasamy Hospital for delivery and she expired. Following this, the matter was investigated by the Director of Medical and Rural Health Services and accordingly a report was submitted before the Joint Director of Health Services. The report concluded that-

"...Based on the above investigations, it is observed that the lapses pointed out by the State Level Committee (Death Audit Committee) are found correct and documentation of treatment given to the deceased Mrs. Krithika was not done properly."

The State Level Committee had found several lapses including - case sheet not documented properly, unavailability of supportive documents, Cephalopelvic Disproportion should have been assessed earlier, progress of labour was not monitored, Post operative monitoring was inadequate etc.

Following this, the Director of Medical and Rural Health Services requested the Council to take appropriate action against those responsible for the death of the patient.

Consequently, Dr. Sangeetha, the treating doctor and Anaesthetist of the Hospital Dr. Thangaraj were summoned for an inquiry by the State Medical Council on 21.10.2021. Meanwhile, in a letter dated 16.10.2021, the JDHS, Erode infromed the Council that another inquiry had been conducted in this regard and from the statements recorded, it was proved that if all the protocols would have been followed by Dr. Sangeetha then the life of the patient could have been saved.

She had further informed the Council that as an appropriate Authority of CEA of Erode District, on Public Interest, she has cancelled the CEA certificate issued to Kumarasamy hospital indefinitely with effect from 18.10.2021 and she was going to file a Civil case before Erode Judicial Magistrate under CEA Act.

On the other hand, Dr. Sangeetha in her explanations had submitted the several reasons in her defense.The doctor also denied any negligence on their part while treating the patient. She also submitted that Kumarasamy Hospital was fully equipped to handle emergency care with relevant equipment and medicine.

It was submitted by the doctor that after the Lower segment Cesarian section (LSCS), the patient had developed sudden cardiac arrest on 18.07.2020. She was resuscitated and Ventillator support was given and cardiac opinion was also sought from the cardiologist of the Hospital. As the cardiologist Dr. N Rajasekhar had advised to shift the patient to a higher facility, the patient was shifted to Sudha Hospitals ICU in an Ambulance. However, despite all efforts the condition of the patient worsened and she expired. The reason for death was claimed to be stress cardiomyopathy.

After the inquiry, the Disciplinary Committee of the Medical Council opined that the possible cause of death was Spinal hypo tension leading to Cardiac arrest or Stress cardiomyopathy or Pulmonary Embolism. However, the Committee also mentioned in its report that Post-mortem of the patient was not done, No ECG was taken after resuscitation, Pre-operation ECG was not clear.

Taking note of the suggestions given by the Committee, summons were issued to Managing Director of Sudha hospitals and the Cardiologist. They argued in the same line and reiterated the same arguments and complaints.

Meanwhile, the complainant referred to the Maternal Death Audit conducted by the State Level Committee at the Kumarasamy Hospital. The committee had also noted that the death was due to Anaesthesia mishandling and inadequate post-operative care. An OGcian Specialist, who attended the inquiry as a special invitee opined that the operation procedure was average and the vitals of the patient were normal. However, Post Op, the doctor left to attend another labour case, when the patient went in sudden cardiac arrest.

The council also consulted a specialist Anaesthesiologist who opined, "On thorough scrutiny of the available record and based on inquiry, the inquiry officer is of the opinion that, the patient was unmonitored for 15 minutes after surgical procedure (though she was retained inside OT by the Anaesthesiolgist for monitoring and observation) and the hypo tension has led to cardiac arrest. By the time it was recognized, it was too late and all resuscitative measures had failed."

While considering the case in its Special Business Meeting held on 20.03.2022, the State Medical Council opined, "The Disciplinary Committee and the Expert Panel are of opinion that except the lapse(f) i.e. Post operative monitoring is inadequate, other lapses would not have caused the death of the patient. As to the allegation that, Post operative monitoring was inadequate, The Disciplinary Committee and the Expert Panel is of the opinion that, after the LSCS, the patient might have left unmonitored and probably during that time, unnoticed, Spinal Anaesthesia induced Hypo-tension, might have occurred, leading to Cardiac arrest of the patient and ultimately resulted in the death of the patient."

Referring to the question if the Gynecologist was negligent in her duties, the Council referred to the opinion given by the Expert Panel and noted, "Even though, the Specialist do not find any fault with the Respondent Dr. Sangeetha, the Council is of the view that, Dr. Sangeetha ought not to have left the patient without full recovery from anesthesia and shifting the patient to the post operative ward/room. Had she remained with the Anaesthetist, she could have helped him to revive the patient, in the emergency situation. The Respondent says that, she left, for seeing another case. But there are eye witness to prove that actually, she went to her house and was seen taking with her husband in front of her house. This is a lapse on the part of Dr. Sangeetha."

The Council also addressed the probable cause of death of the patient and observed, "Disciplinary Committee and the expert panel were of the opinion that one of the probable reasons for death could be due to massive acute pulmonary embolism. But the Cardiologist was sure that, it was not Pulmonary embolism as he found during echo-cardiography that, RA and RV were not dilated. The Anesthesiologist Specialist is of the view that sudden Cardiac Arrest,without any premonitary signs is very unlikely in a healthy 22 year old female without any co morbid conditions. Spinal hypo-tension usually responds to intravenous fluids and vasopressors, if, intervened at the right time. Since, the surgical time was short i.e. 25 minutes and the duration of the spinal blockade would be much longer probably spinal Anaesthesia induced hypo-tension would have been unmonitored and subsequently, the intervention that was given, that too manual CPR given, was very late, as a defibrillator was not available in the Hospital, hence favourable outcome was not achieved and the patient could not be revived."

Although the Council exonerated the cardiologist, it opined, "The Council endorses with the views of Anethesiologist Specialist and comes to the conclusion that, the patient was probably unmonitored for 15 minutes after surgical procedure (though she was retained inside OT by the Anesthesiologist for monitoring and observation) and the unnoticed anesthesia induced hypo-tension has led to cardiac arrest and Anesthesiologist Dr. Thangaraj was negligent on his duties and not monitored the patient properly for about 15 minutes and thereby failed in his legitimate duty to attend the patient."

Holding the treating Gynecologist and the Anesthesiologist negligent in their duties, the Council noted, 

"(i) Dr. Thangaraj, has derelicted his legitimate duties in caring the patient and left the patient unattended for some time after LSCS and there by missed an early diagnosis of Spinal anesthesia induced hypo-tension which led to hypo-tension and ultimately in the death of the Patient and accordingly he is guilty of having committed civil negligence, in this case

(ii) Dr. Sangeetha, left the patient soon after the L.S.C.S, leaving the patient at the care of Anesthesiologist, before recovery of the patient from anesthesia, which is a lapse on her part."

Therefore the Council decided, 

"(a) That, the name of Dr. Thangaraj be removed from the Medical Register of Tamil Nadu Medical Council for a term of 6 months.

(b) That, Dr. Sangeetha be warned to be more careful in future."

"Accordingly, it is ordered that, the name of Dr. Thangaraj, is removed from the Medical Register of Tamil Nadu Medical Council for a term of one year and Dr. Sangeetha is warned. It is made clear that, Dr. Thangaraj should not practise modern medicine during the period, his name is erased from the Medical Register of Tamil Nadu Medical Council.nDr. Thangaraj is directed to surrender his original Registration Certificate to Tamil Nadu Medical Council, immediately," read the order.

To read the order, click on the link below.

https://medicaldialogues.in/pdf_upload/tamil-nadu-medical-council-173660.pdf