Bacterial infection post knee replacement surgery: NCDRC absolves Orthopaedician, Fortis Hospital, dismisses Rs 1 crore compensation case

The case concerns a 68-year old patient, who underwent bilateral Total Knee Replacement (TKR) Surgery at Fortis Hospital, Noida in 2007 performed by an Orthopedic Surgeon and his team.

Medical record revealed that the patient's blood culture grew Acinetobacter, a type of bacteria with high virulence. The patient was already on antibiotics, and the antibiotics were revised on the basis of blood counts. After few days, the patient suffered an episode of Acute Hypertension (dangerously High BP) and Left ventricular failure.

The Culture samples of blood and Endotracheal (ET) aspirate showed Pseudomonas bacterial growth. The secretions were regularly aspirated by external suction machines. The doctors were able to control Acinetobacter as the blood cultures done on 4th, 6th and 14th June 2007 were negative, but the Pseudomonas infection failed to respond the treatment.

The patient, thereafter, developed resistance to most of the Antibiotics. Later on, the patient's condition continued to deteriorate and the patient developed Sepsis with Acute Respiratory Distress Syndrome (ARDS) and Multiorgan Failure (MOF) including Respiratory failure and kidney failure. She developed cardiac arrest, despite cardiopulmonary resuscitation performed as per ACLS guidelines, the patient could not be revived and was declared dead.

However, it was alleged that surgeon never disclosed about the real condition of the patient and the hospital issued one incomplete handwritten case summary, devoid of details of Acinetobacter and Pseudomonas infection.

Being aggrieved, the deceased patient's father filed the instant consumer complaint and prayed for Rs. 1,37,89,556/- and other reliefs.

The counsel for the complainant argued that the untimely death of the patient was due to hospital acquired infection, adding that it was due to careless and negligence during post-operative care. He further argued that prior to the admission to the hospital, the patient had no infection or any other major illness. The blood tests and other investigations were normal.

He further submitted that the brother-in-law of the complainant lodged an FIR under Section 304 A IPC against . It was challenged by the surgeon before the High Court of Allahabad. Accordingly, the District Magistrate of Gautam Budh Nagar directed the Chief Medical Officer (CMO) to constitute a team of expert doctors/medical board to enquire in the matter.

The Medical Board, vide its report held that the Orthopedic Surgeon was not guilty of negligence. The Investigating Officer submitted his final report before the court of Chief Judicial Magistrate, Noida. The brother-in-law of the complainant filed protest petition, but the Court upheld the final report. However, the Court in its order observed that as far as the question of generation of bacteria by the infection in the ICU after operation, it creates doubt that Fortis may be at fault.

On the other hand, the counsel for the doctor submitted that the Orthopedic Surgeon has national repute and specialization in the field of Knee Replacement. He was (then) the Chairman and Executive Director - Fortis Escorts Heart Institute, Okhla Road, New Delhi.

The Counsel further submitted that;

"The complainant has not furnished any iota of evidence to substantiate her allegations. The role of the doctor as an Orthopedic Surgeon was limited to the procedure of bilateral TKR. It was done successfully and the surgical site did not develop any infection. It was healed completely. As per the Death Certificate, the direct cause of death of the patient was "Severe Respiratory and Metabolic acidosis leading to Asystole". It was not, in any way, connected with the TKR Surgery. There was no negligence during TKR surgery. It is supported by the opinion of the Medical Board constituted after the direction of the Hon'ble High Court of Allahabad. Therefore, the subsequent infection, which was contracted, cannot be attributed to the TKR procedure. In fact, the stitches of the wound were removed and the wound was healed satisfactorily. The treating team of doctors performed their duties with reasonable skill and competence in the best interest of the patient. No case of medical negligence is made out. "

On perusal, the Commission noted that the surgeon on support of his case, filed opinions from two experts - one from Dr. Yatin Mehta, a Critical Care Specialist, presently Chairman at Institute of Critical Care & Anesthesiology at Medanta-the Medicity, Gurgaon and Dr. P.K. Dave, Orthopaedic Surgeon, the ex-Director of AIIMS.

"Both have opined that there was no negligence in the Surgery conducted by the Orthopedic Surgeon . The subsequent infection contracted by the patient of Pseudomonas and Acinetobacter organism was independent of the surgery in the present case," it noted.

NCDRC further perused the opinion of Medical Board, issued by the District Hospital, Noida that observed;

1) Medico-Legal point of view, cause of Death is not established as Autopsy not done.

2) Reasonable efforts were made to treat the infection by Medical Team in ICU of Fortis Hospital, Noida.

3) Incidence of death by Acinetobacter/Pseudomonas bacteria producing "Ventilator Associated Pneumonia" in ICU set up is an established fact and reported to have occurred at the best of Medical Centers/Hospitals in the World over.

The Medical Board opined that there was no evidence of any rashness/omission and/or negligence by the doctor, while treating the patient. The board also relied upon the Bolam test, which is the accepted benchmark to establish medical negligence.

The apex consumer court observed;

"The Orthopedic Surgeon, whose role as a Surgeon was to operate to the best of his ability with due care and caution, performed TKR successfully and the surgical wound was healed well and the stitches were removed. The subsequent infection and the complication cannot be attributed to the act of the surgeon. The patient was constantly monitored and treated by a team of doctors from various specialties in the Critical Care field, Cardiologist, Pulmonologist, Gastroenterologist and Nephrologist as and when they were required."

It added;

"In our considered view, the team of doctors performed their duties with reasonable skill and competence. We do not find any deviation from the accepted standard of practice to transfuse 2 units of RRBC after major surgery. As a mandatory protocol and caution, the DVT Prophylaxis in the form of Inj Enoxaparin and graduated pressure Stockings were given. Thus, no case of medical negligence was made out."

It held that the complainant failed to prove his case adding that the allegations need to be proved with cogent evidence. NCDRC relied upon the recent judgment passed by the Hon'ble Supreme Court in Bombay Hospital & Medical Research Centre vs. Asha Jaiswal & Ors.[1], whereby it was held in paragraphs 32 and 34 of judgment as below:-

32. In C.P. Sreekumar (Dr.), MS (Ortho) v. S. Ramanujam [2], this Court held that the Commission ought not to presume that the allegations in the complaint are inviolable truth even though they remained unsupported by any evidence.

34. Recently, this Court in a judgment reported as Dr. Harish Kumar Khurana v. Joginder Singh & Others[3] held that hospital and the doctors are required to exercise sufficient care in treating the patient in all circumstances. However, in an unfortunate case, death may occur. It is necessary that sufficient material or medical evidence should be available before the adjudicating authority to arrive at the conclusion that death is due to medical negligence.

Subsequently, it held;

"In the obtaining facts and the available evidence on record, it is not feasible to conclusively attribute non-adherence to duty of care and standard of practice, it is difficult to conclusively establish medical negligence / deficiency on the treating doctor and the hospital. The Complaint is dismissed. The parties to bear their own costs."

To view the original order, click on the link below:

http://cms.nic.in/ncdrcusersWeb/GetJudgement.do?method=GetJudgement&caseidin=0/0/CC/88/2009&dtofhearing=2022-08-26