Eye hospital, Ophthalmologist, Anaesthetist directed Rs 1 crore compensation 22 years after patient died during squint eye correction surgery

New Delhi: Holding an eye hospital, its operating Ophthalmologist and anaesthetist guilty of medical negligence while conducting squint eye correction surgery, the National Consumer Disputes Redressal Commission (NCDRC) has recently directed them to pay Rs 1 crore compensation to the parents of a patient, who died on the operation table.

The top consumer court held the anesthetist guilty for not warning the operating surgeon about possible reaction from a medication and also held the hospital vicariously liable for the death of the patient 22 years ago.

The son of the complainants, who was about 6 years of age back in 2000, had been taken to Chennai at Sankar Nethralaya. After examining the patient, Dr. S Agarkar had advised a minor surgery to correct the squint. She had proposed the name of Senior Surgeon - Dr. T. S. Surendran for the operation.

After preoperative investigations, blood and urine tests, a doctor had noticed faint functional systolic 'murmur' and chest wall abnormality. The same was brought to the notice of Dr. S. Bhaskaran, a Senior Cardiologist, who further examined the child with some exercises and concluded about no murmur and he also ruled out further need for any tests like ECG, ECHO or Chest X-ray etc.

Therefore, the child had been declared to be "Fit for General Anesthesia" and before the operation, the child had been administered three injections at around 3.00 p.m. on 14.06.2000. Around three hours later, the complainants had been informed about the death of the child on the operation table. 

Further they alleged that the hospital had issued patient's case summary after two days and the discharge summary was vague without any details of Cardio Pulmonary Resuscitation (CPR) and the happenings in the operation theatre. Despite repeated requests, the doctors had failed to provide the complete medical record. Therefore, the complainants had approached the Prime Minister's Office and finally after six months entire medical record including the Post mortem report had been handed to the Complainants.

Apart from this, it was further alleged by the Complainants that there was excessive gap between the last oral intake and commencement of the surgery. Thus, the child was kept on fasting for 9 hours 20 minutes, due to which he became hypoglycemic, which could lead to cardiac arrest. Halothane was used as an anesthetic agent which was known to cause bradycardia (heart rate slows down). Atropine was given as a pre-medication in all the cases to prevent bradycardia.

Therefore, the child was not administered the correct dose at the right time and there was a huge gap between atropinization and actual surgery. The Anesthetist failed to intubate, which was the cause of death. Besides, the complainants claimed that on that very day, Dr. T. S. Surendran had already completed 16 operations and there was no hurry to operate on the child on the very day itself, wherein high degree of care was needed. 

Alleging gross medical negligence and being aggrieved by the same, the complainants approached the NCDRC bench and prayed for Rs. 1,00,20,000/- as compensation.

It was argued by the counsel for the Complainants that the squint surgery was an elective surgery, and not an emergency. The counsel contended that the operating surgeon was unaware about the special warnings for using Scoline in pediatric cases and the anesthetist failed to warn to the surgeon about it. Besides, the counsel for the complainants referred to the fact that the deceased was the only child and the mother already underwent hysterectomy in 1997, therefore losing her chance of another child.

On the other hand, the doctors and the hospital filed their replies and denied allegations of negligence. However, they expressed their deep sympathies for the death of patient. It was submitted that as per medical guidelines, routine pre-operative ECG, ECHO and Xray were not necessary for children and persons below the age of 40 years accept medically warranted.

The hospital submitted that it was equipped with all the infrastructure and operation theatre (OT) including monitor, centralized Oxygen and all facilities for administering GA or any type of anesthesia for performing squint surgery. Referring to the procedure of operation, the hospital submitted that all the procedures had been followed including CPR, cardiac thump, external cardiac massage, DC shock for reviving the patient. Dr. S. Bhaskaran, Cardiologist joined in the resuscitation efforts. In spite of all resuscitative measures, the patient could not be saved.

The Government of Tamilnadu, in response to the representation made by the Complainants to the Prime Minster and the Railway Minister, appointed four - committees to enquire the matter. After enquiry, the committees did not observe any adverse comment or report on the hospital facilities and on the treatment aspect. The death was occurred due to Cardio-respiratory arrest.

The counsel for the hospital and doctors submitted that the entire treatment had been done as per the standard of practice. Further, the treatment had been reviewed by four independent committees of experts, who had not made any adverse comment or report on the treatment aspect and hospital facilities etc.

After considering the submissions by both the parties, the NCDRC bench perused the entire material on record including the Medical Record for the concerned case.

While considering the role of the cardiologist, the Commission noted that "No doubt, the child was about 8 years, school going, thus, there was less possibility of congenital anomaly. But, we cannot ignore that the child was suffering from bilateral squint and chest deformity, which were congenital anomalies. Therefore, the cardiac anomalies cannot be ruled out in this case. Moreover, if one physician (MD) notices functional murmur, then the expected skill from the Super Specialist i.e. the Cardiologist was more and higher degree of care should be there. It is lacking in the instant case and unfortunately, the child was declared fit for GA."

In this regard, the Commission referred to the opinion by Dr K P Mishra, a senior Cardiologist who had supported the method of diagnosis by the concerned Cardiologist. However, the NCDRC bench noted, "We do not accept the evidence of Dr. Mishra in totality for the reasons stated in para (i). In our view, it was the failure of duty of care and the casual approach of the Cardiologist. Moreover, the entries made in the progress report appear to be an afterthought and added later on."

Further referring to the medical procedure, the Commission observed, "We do not find any significance about fasting state of child. Several studies revealed that there is no uniform fasting practice for children before effective surgery. Fluids in small quantity are acceptable 2-3 hours prior to GA. The Complainant No.2 (father) signed the Informed Consent. The child was not administered Atropine in correct dose at proper time. We don't find importance to the pre-medication by Atropine for Antisialagogues to decrease the flow rate of saliva is not routinely used. In the recent days it is not regularly in practice by the Anesthetist."

When the bench considered the process of intubating the child, it noted, "In the Instant case, as the vocal cord was anterior, it was not possible to intubate the patient in the first attempt. It is not clear from the record that Scoline was administered before first intubation, as such the possibility cannot be ruled out."

"...it is pertinent to note that use of Scoline further precipitated the bradycardia which was already occurred due to Halothane anesthesia," it further observed.

The Commission opined, "In our considered view it was the Oculocardiac Reflex (OCR), also known as the Aschner reflex or trigeminovagal reflex (TVR). It is a reduction in the heart rate secondary to direct pressure placed on the eyeball. It is defined by a decrease in heart rate by greater than 20% following globe pressure or traction of the extraocular muscles. Most commonly, the reflex induces bradycardia. However, OCR also has a reported association with reduced arterial pressure, arrhythmia, asystole, and even cardiac arrest. This reflex has most notably been depicted during ophthalmologic procedures, more specifically during squint / strabismus Ocular Surgery...Therefore, in the instant case the Intra-Operative diagnosis of OCR was missed and the child suffered Cardiac Arrest. The patients who are considered at-risk for the OCR should warrant particular attention."

Further the Commission noted that "all drugs used in anesthesia have adverse minor to major life threatening complications. Anesthetists are aware of such effects and use the drugs depending on the patient, nature and requirements of surgery, disease profile and the situation."

Referring to the medical record, the Commission expressed its confusion regarding giving the patient Atropine and how it was administered.

"The failed intubation cannot rule out possibility of wrong intubation (in the esophagus). After failed 1 st intubation, Scoline was injected for 2 nd intubation and then child suffered hypoxia- bradycardia and arrest. In our view it was the effect of Halothane and Scoline. The anesthetist (OP-3) should have altered/ cautioned the operating surgeon (OP-2) about the warning signs of Scoline. The surgeon was not aware that any special warnings for the use of Scoline in pediatric cases," further noted the consumer court.

Apart from this, the top consumer court also agreed with the complainant's counsel that "surgery could have been abandoned." Referring to the busy schedule of the operating surgeon, the Commission noted,

"Therefore, the question arose in our mind why the squint surgery was not deferred to another date. Moreover, it was a planned surgery and there was not an emergency at all or the Complainants have not forced for it. The child was not co-operative. Halothane was used as an anesthetic agent, a known hypotensive. During the procedure, after removal of halothane and nitrous oxide mask, there was difficulty in intubation. The 1 st attempt was failed and therefore, the Opposite Party No. 3 intubated by injecting relaxant – injection Scoline, which also induces bradycardia. Thereafter, there was reduction of oxygen saturation and the child suffered cardiac arrest. The discharge / death Certificate did not mention about intubation for general anesthesia."

At this outset, the Commission referred to the laws laid down by the Supreme Court regarding medical negligence in the case of Kusum Sharma and ors v. Batra Hospital and Medical Research Centre & Ors., Dr. Laxman Balakrishna Joshi vs. Dr. Trimbak Bapu Godbole & Anr, and A.S. Mittal vs. State of U.P.

Thereafter, holding the Hospital vicariously liable for the acts of medical negligence committee by the doctors, the commission observed,

"...when a patient goes to a hospital, he/she goes there on account of the reputation of the hospital, and with the hope that due and proper care will be taken by the hospital authorities. If the hospital fails to discharge their duties through their doctors, being employed on job basis or employed on contract basis, it is the hospital which has to justify the acts of commission or omission on behalf of their doctors."

Considering the fact that there was no chance for the mother of the deceased for having another child, and also after taking note of the fact that the litigation was pending for 20 years, the Commission awarded the complainants with Rs 1 crore compensation and noted, "In the instant case, since, the Cardiologist – Dr. Bhaskaran has not been arrayed as a party, therefore, monitory liability cannot be fixed upon him, and therefore, the OP-1 is held vicariously liable. Accordingly, we direct the Sankara Nethralaya (OP-1) to pay Rs. 85 lakh; the Anesthetist, Dr. R. Kanan (OP-3) shall pay Rs. 10 lakh and the operating Ophthalmologist, Dr. T. S. Surendran (OP-2) shall pay Rs. 5 lakh to the parents of the deceased child (Complainants) within 6 weeks from today. Beyond 6 weeks, the amount shall carry interest at 9% per annum till its realization. The OP-1 shall further pay Rs. 1 lakh towards cost of litigation."

To read the order, click on the link below.

https://medicaldialogues.in/pdf_upload/sankar-nethralaya-medical-negligence-184870.pdf

Also Read: Vague Allegations cannot be Grounds for establishing Negligence: Delhi Consumer Court exonerates Ophthalmologist