Emergency hysterectomy in Placenta praevia grade IV case: Consumer Court exonerates hospital, Gynaecologist, surgeon, anaesthetist

The history of the case goes back to 2015, when at R.P. Memorial Hospital, an MTP procedure was carried out on the complainant's wife by the treating doctors at the hospital. It was alleged that due to the negligence in treatment, the patient died on 13.07.2015 at Lady Hardinge Hospital.

It was submitted by the complainant that after the patient was admitted to the treating hospital, her pregnancy was terminated by a team of doctors. At that time, she was about 18-19 weeks pregnant. Further, allegedly, her condition became serious and critical due to the negligent performance of an illegal MTP procedure without following prescribed protocols, and thereafter she was shifted to Lady Hardinge Medical College & Smt. Sucheta Kriplani Hospital (LHMC), New Delhi, where she was left unattended in front of the emergency ward.

He further alleged that the doctors of RP Memorial Hospital performed an 'illegal' hysterectomy (termination of pregnancy) without the consent of the patient, without obtaining a second opinion from any senior gynecologist, and without the involvement of any expert or experienced doctor.

During the procedure, the patient’s condition deteriorated due to heavy blood loss, resulting in hemorrhage, disseminated intravascular coagulation, hypovolemia, and ultimately multiple organ failure. The patient was then shifted to LHMC without a discharge slip or referral letter, in a private van, and without adequate medical staff. The complainant alleged that she was left unattended in front of the gynecology casualty at LHMC and remained unattended for more than four hours, and when the treatment finally started, despite the best and genuine efforts by the LHMC staff, the patient died on 13.07.2015 at 4:30 a.m. during treatment.

An FIR was registered in this connection at PS Nangloi under Section 315 IPC. After conducting an inquiry through its Disciplinary Committee regarding the role of the doctors, the Delhi Medical Council passed an order dated 17.10.2019 holding the treating doctors guilty of medical negligence. It observed that one of the treating doctors- a general surgeon, performed procedure beyond his competence. Vitals, anaesthesia chart and proper consent were not maintained, piecemeal removal of the placenta led to torrential bleeding, and the hospital also lacked adequate facilities. Further, the Council held that the patient should have been referred earlier. The registration of the general surgeon was suspended and warnings were issued to the other three doctors. Later, the Ethics Committee of the National Medical Commission (NMC) affirmed the DMC findings.

The complainants filed a consumer complaint and sought compensation for unnatural death caused by negligence, loss of companionship and life amenities, deprivation of maternal care, love and affection, emotional distress and suffering, etc.

On the other hand, the hospital and the treating doctors denied that the patient's pregnancy was terminated by a team of doctors. It was alleged that the Medical Superintendent of the hospital and the Gynecologist were not involved in any surgical procedure or assistance and it was not a case of pregnancy termination, but a case of hysterotomy performed by the general surgeon and anaesthetist to save the patient's life and it was done in good faith. A dead male baby was extracted, the placenta was badly adhered and did not separate spontaneously. Placenta was removed manually in pieces, but the bleeding did not stop as it was a case of placenta accreta, which is a known medical complication.

They also denied the allegation that the patient's condition became serious and critical due to any alleged negligent or illegal MTP procedure, or that, when the situation went out of control, the doctors shifted the patient to Lady Hardinge Medical College (LHMC) & Smt. Sucheta Kriplani Hospital, New Delhi and left her unattended in front of the emergency ward. It is stated that no abortion procedure was done at by the treating doctors, but a hysterectomy was performed with the consent of the patient, and the consent form (R-3) was duly signed by both the patient and her husband.

It was also stated that proper care was taken to control the bleeding- both iliac arteries were ligated, blood transfusion was arranged, Haemaccel and Dopamine drip were administered, oxygen support and vaginal packing were provided. Thereafter, the patient was referred to Lady Hardinge Hospital in a stable condition, with all preventive measures and protocols duly followed. Alleging that the patient was left unattended at LHMC for about three hours even after receiving the referral slip, the treating hospital and doctors denied any negligence on their part.

Claiming that the NMC order suffered from non-appreciation of facts, the hospital and doctors submitted that the evidence produced by the general surgeon, including the death summary of the deceased patient and the treatment procedure adopted by the doctors at LHMC were not considered. It was also submitted that the general surgeon operated on the patient as it was an emergent situation and gynaecologists were not available. 

On examination, the general surgeon found that the patient was about 18–19 weeks pregnant with severe bleeding per vaginum due to placenta previa grade IV. The patient had been bleeding profusely even before arrival. It was a case of spontaneous abortion. In such an emergent situation, immediate surgical intervention was necessary to save her life. Therefore, the doctor decided to operate and evacuate the uterus (hysterotomy) to control the profuse bleeding as a life-saving measure. The treatment provided under such emergency does not amount to transgression from general surgery into gynecology, but was a life-saving necessity, they argued.

The surgeon submitted that a dead foetus with two loops of cord around the neck was delivered. The placenta did not separate spontaneously due to previous LSCS and was adherent to the scar. So, the doctor manually removed the placenta, but part remained adherent, which was later separated by blunt curettage and sponge. However, bleeding continued. Since the consent for hysterectomy was not given by the patient's attendants, considering the patient's critical condition and lack of ICU facilities, the anaesthetist advised referral to a higher center. Accordingly, the patient was referred to Lady Hardinge Medical College with a referral slip, dopamine drip, packed RBCs, and oxygen support.

The death summary at LHMC recorded that the cause of death was: “exploratory laparotomy with obstetric hysterectomy (total) with bilateral internal iliac artery ligation with DIC, multi-organ failure, and cardiorespiratory arrest.”

Subsequent forensic opinion confirmed that termination of pregnancy was done as a life-saving measure considering the imminent danger to the patient’s life.

Observations by Commission: 

While considering the matter, the Commission observed that it is a settled principle of law that to fasten liability of medical negligence, it must be shown that the medical professional failed to exercise a reasonable degree of care, skill, and knowledge which an ordinary competent practitioner would have exercised in similar circumstances.

Applying the principles set by the Supreme Court in the case of Jacob Mathew vs State of Punjab, Kusum Sharma & Ors. vs. Batra Hospital & Medical Research Centre & Ors, and in the recent case of Deep Nursing Home and Another vs. Manmeet Singh Mattewal and Others, the consumer court observed,

"Applying the above principles to the present case, it is evident that the deceased was suffering from a critical condition of placenta praevia GradeIV. The patient came with a report of Mahendru Hospital E-1 Karan Garden, Uttam Nagar as a case of complete Placenta previa Grade IV and pain in abdomen... The termination of pregnancy was not a routine procedure but was performed in good faith as a life-saving measure. The records show that consent was obtained from the patient herself, duly witnessed by her husband. There is nothing on record to suggest that the Opposite Parties deviated from the accepted medical practice or failed to exercise reasonable care and skill expected of qualified medical professionals."

Referring to the Delhi Medical Council's order, the Consumer Court further observed that the hospital maintained operative notes, referral information, and post-operative management records. While some vitals were not recorded continuously, the hospital staff documented key interventions, including blood transfusions, administration of necessary medications, and the surgical steps undertaken.

"The procedure, namely termination of pregnancy/hysterectomy, was performed in a medically critical scenario involving placenta praevia with active bleeding. The attending medical team obtained consent in accordance with hospital protocol to the best extent possible under the emergent circumstances. During the procedure, the hospital identified serious complications and promptly referred the patient to a higher medical facility, Lady Hardinge Medical College (LHMC), for specialized care. The referral was made in line with the patient’s emergent needs, demonstrating the hospital’s intention to ensure timely and appropriate treatment. Upon arrival at LHMC, the patient received resuscitative and surgical interventions. Despite the best efforts of both the original treating team and LHMC, the patient unfortunately succumbed due to complications arising from a high-risk pregnancy with pre-existing placenta-related issues. The outcome reflects the severity of the patient’s condition rather than any deliberate negligence on the part of the hospital or treating doctors," observed the Commission.

"The available medical records, operative notes, and expert opinion collectively demonstrate that the Opposite Parties acted in good faith, followed reasonable medical procedures under emergency circumstances, and sought higher-level care appropriately. Any procedural lapses were inadvertent and do not constitute deliberate medical negligence," it further held.

Opining that the complainant was treated as per standard medical protocol, the Commission held that the treating doctors and hospital cannot be held negligent.

It observed,

"Therefore, we hold that the Opposite Parties cannot be fastened with liability for medical negligence merely because the patient, despite best efforts, could not be saved. The unfortunate demise of the patient, though deeply regrettable, cannot be attributed to any deficiency in service or medical negligence on the part of the treating doctors."

Apart from this, the Commission also observed that even though the complainant alleged medical negligence, no expert evidence was filed to substantiate such allegations.

"In the present case, the complainant has not placed on record any independent expert opinion from a competent medical professional or medical board to establish that the treatment given by OPs 2 to 5 (doctors) was contrary to established medical standards. The complainant has relied primarily on averments in the complaint and on the unfortunate outcome of the treatment. No expert affidavit or testimony has been filed to demonstrate that the procedure adopted by the treating doctors was wrong, improper, or negligent," observed the Commission.

"It is well settled by judicial pronouncements that in cases of alleged medical negligence, especially involving complex medical procedures, the burden lies upon the complainant to establish negligence by producing cogent evidence, which generally includes expert medical opinion. The Hon’ble Supreme Court in Jacob Mathew v. State of Punjab [(2005) 6 SCC 1] held that a doctor cannot be held guilty of negligence simply because the treatment was unsuccessful or resulted in an adverse outcome. To establish negligence, it must be shown that the doctor acted in a manner that no reasonable medical professional would have acted in similar circumstances," it further noted.

Holding that the allegations of medical negligence remained unsubstantiated, the Commission observed,

"In the absence of expert evidence, the complainant has failed to discharge the burden of proof. The mere fact that the patient could not be saved, despite the efforts of the treating doctors, does not amount to negligence. The medical records on the contrary support the version of the Opposite Parties that the deceased was suffering from placenta praevia Grade-IV — a high-risk condition — and the termination of pregnancy was performed as a life-saving measure after due consent. Accordingly, we hold that since the complainant has not filed any expert evidence in support of the allegations, the charge of medical negligence remains unsubstantiated."

Regarding the issue of proper medical consent, the Commission observed that the patient was suffering from complete placenta praevia Grade-IV, a life-threatening obstetric condition and the medical records showed that the consent for termination of pregnancy was signed by the patient herself and duly witnessed by her husband. Therefore, the procedure was not performed in secrecy or without authorization.

"Even otherwise, in cases where the condition is emergent and delay in treatment may endanger the life of the patient, the law recognizes that doctors are permitted to act in good faith for the best interests of the patient. This principle is consistent with the exception carved out by Hon’ble Supreme Court in Samira Kohli (supra)," noted the Commission.

With all these observations, the Consumer Court dismissed the complaint and noted, "Thus in view of the above findings, we hold that the complainant has failed to establish medical negligence or deficiency in service on the part of the Opposite Parties No.1 to 5. Consequently, the complaint stands dismissed. There shall be no order as to costs."

To view the order, click on the link below:

https://medicaldialogues.in/pdf_upload/dcdrc-new-delhi-no-medical-negligence-304586.pdf

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