Failed Tooth Extraction Leads to 14 Surgeries, Amputations: NCDRC orders Rs 50 lakh compensation on Narayana Hospital Jaipur, doctors for therapeutic misadventure

The NCDRC bench of Subhash Chandra (presiding member) and air vice-marshal (AVM) J Rajendra (retd) (member) observed that the doctors were found wanting in all the counts as discussed in the Supreme Court judgement in the case of Dr Laxman Balakrishna Joshi vs Dr Trimbak Bapu Godbole. "It was not even bona fide mistake, but a therapeutic misadventure," the bench noted.

The case involved two appeals, arising from an order issued by the State Consumer Disputes Redressal Commission, Rajasthan in 2019, concerning the patient, Singh as the appellant/complainant and Narayana Multispeciality Hospital and others (a doctor and a cardiac consultant) as respondents/opposite parties.

Singh's complaint detailed his visit to Soni Hospital for his wife's routine check-up and his consultation with a dentist there regarding a dental issue. The dentist advised tooth extraction scheduled for 23/03/2017. During the extraction procedure, Singh experienced severe pain, leading to his hospital admission. Doctors recommended angiography due to low blood pressure and seizures. This revealed blockages in his arteries, and doctors suggested stent placement. After seeking a second opinion, he consulted Narayana Hridayalaya Ltd., where stent placement was advised by a cardiac consultant. Following the procedure, the patient experienced chest pain and complications leading to multiple surgeries and eventual amputation due to gangrene.

Aggrieved, the patient filed a complaint before the State Commission alleging medical negligence and sought compensation of Rs 98 lakhs. However, the hospital and the doctors denied negligence, emphasizing that comprehensive discussions were held before procedures and the patient's consent obtained. They contended that the complications arose due to the patient's existing Peripheral Vascular Disease and other health conditions.

The State Commission partly allowed the complaint, directing Narayana Hrudayalaya to pay Rs 30 lakhs and the two doctors Rs 10 lakhs each, totaling Rs 50 lakhs, along with 9% interest from the complaint's filing date.

In the aftermath of the State Commission's ruling, both Singh, the complainant, and Narayana Hridayalaya Ltd., the opposing parties, filed cross-appeals presenting distinct arguments and seeking specific remedies. Singh, in his appeal, urged the apex consumer body to overturn the State Commission's decision and grant a more comprehensive compensation aligned with the severity of his disability. He emphasized the profound impact on his family's financial stability, highlighting their reliance on his inadequate pension as the sole breadwinner. Meanwhile, the hospital and the associated doctors, in their appeal, challenged the State Commission's assertion regarding the lack of consent for the angioplasty procedure. They contested the presented evidence and stressed their efforts to save the patient's life, rejecting any claim of negligence.

Singh's counsel emphasized medical negligence due to inadequate examination and lack of informed consent, asserting that the awarded compensation did not commensurate with the severe harm suffered. In contrast, Narayana Hridayalaya Ltd.'s counsel refuted any negligence and argued the disproportionality of the compensation, citing legal precedents. Both parties urged NCDRC to refer the medical records to an expert Medical Board while Narayana Hridayalaya Ltd. sought the dismissal of Singh's appeal or reimbursement if dismissed. The appeals presented opposing views on medical negligence and compensation adequacy, indicating a necessity for thorough scrutiny of medical records and expert opinions to establish the case's factual basis.

After careful consideration of the pleadings and the associated documents, along with extensive arguments presented by both parties' learned counsels, the Commission opined that the factual sequence emerged unquestionably. Singh initially visited Soni Hospital in March 2017 due to toothache and underwent an examination suggesting tooth extraction to prevent potential complications. Scheduled for extraction on March 23, 2017, he encountered severe pain during the procedure, prompting hospital admission. Upon examination, doctors recommended an angiography due to low blood pressure and seizures, and due to its urgency, his family was sought for consent. The angiography unveiled blockages of 60%, 70%, and 100%, requiring stenting. However, as he initially visited the hospital for a dental concern, immediate stenting was not feasible. Seeking a second opinion from Dr Vijay Pathak at Sawai Mansingh Hospital, he was advised medication instead of immediate stent placement. Subsequently, Singh consulted Narayana Hridayalaya Ltd., a specialized heart facility, where he was advised by Cardiac Consultant to undergo stent placement.

On April 3, 2017, Singh underwent the stenting procedure at 12:00 PM but complained of chest pain upon regaining consciousness at 4:00 PM. Assured by the Cardiac Consultant that such pain post-stent placement was normal, he discovered that contrary to the pre-surgery assurance of stent insertion via hand veins, the catheter had been placed through his leg veins. As the chest pain persisted and intensified, medical examination revealed a puncture in his heart causing bleeding and blood accumulation, warranting immediate action in the operating theatre (OT). Despite efforts to stop the bleeding through an incision, the situation escalated, prompting administration of a blood-thickening injection. Subsequently transferred to the ICU, the patient reported loss of sensation in his right leg, progressively leading to a diagnosis of gangrene. Urgent surgeries by the doctor ensued throughout the night, addressing severe heart bleeding and the compromised leg, leading to multiple operations totaling 14 surgeries.

The deteriorating medical condition compelled successive amputations: first, the leg below the knee due to infection risk, followed by further amputation to the hip joint. Subsequent infections, blood accumulation in the lungs, impaired vision in the right eye, and persistent unhealed surgical wounds necessitated continuous medical attention every 5-7 days. The patient sought compensation for the substantial physical, emotional, and financial hardships resulting from the multiple surgeries.

Analysis of the case revealed an undeniable series of 14 surgeries, 42 blood transfusions, and subsequent gangrene, initially leading to leg amputation below the knee and eventually extending up to the hip. Notably, the opposing parties (OPs) failed to provide an explanation for the gangrene's development. Furthermore, the patient suffered a ruptured heart leading to substantial bleeding and subsequent lung operations. The sequence of events leading to multiple surgeries, including amputations and other critical interventions, raised serious concerns regarding the unexpected complications arising from a dental visit and subsequent medical procedures. The Commission noted that the burden to justify the lack of negligence lied with the OPs once the complainant establishes his contentions and factual version, as clarified by the Supreme Court in Smt Savita Garg vs Director, National Heart Institute, IV (2004) CPJ 40 (SC). It observed;

"There is no explanation given by the OPs as to why this gangrene developed. Further, his heart was ruptured, and it started bleeding. To stop bleeding, several operations were conducted. Also, the blood entered his lungs and even lungs were operated upon. No reasonable explanation was rendered as to why such situations arose wherein a patient who went for a tooth extraction ended up with one leg amputated up to hip bone, heart ruptured, and blood in the lungs and multiple surgeries. Thus, the Complainant prima-facie succeeded in establishing his contentions and version of the facts stated."

The Commission was of the view that considering the duty of care in medical contexts, particularly in contractual relationships, the obligation to treat translates into a legal duty to take care of the patient's well-being. In the case at hand, the specialized nature of Narayana Hridayalaya Ltd. raised expectations of superior care, but the procedures and outcomes contradicted these expectations. Despite the patient's consent for angioplasty via hand veins, its execution through leg veins without documented consent posed a significant ethical and possibly legal dilemma, referencing the observations made by the Supreme Court in Samira Kohli vs. Dr. Prabha Manchanda & Anr. (2008) 2 SCC 1.

The established patient history of Peripheral Vascular Disease (PVD) in both legs compounded the risk factors involved in the treatment. The decision for angioplasty in a patient with Triple Vessel Disease (TVD) and known PVD introduced complexities with increased chances of complications, a matter also addressed by the cardiac Consultant. The failure to conduct proper assessments and the discrepancies between consent and the actual procedure cast serious doubts on the hospital's decision-making and adherence to medical ethics and standards, the Commission added in its observation.

It said that the established factual sequence, the medical history of the patient, the procedural decisions, and their unexpected complications raise grave doubts regarding the standard of care and the ethical integrity of the medical procedures undertaken.

Upon examining the case thoroughly, it remains unclear why the Complainant experienced continuous bleeding from the foot where the catheter was inserted for angioplasty and from the heart, leading to emergency situations. Despite the Complainant's leg issues due to Peripheral Vascular Disease (PVD), angioplasty was performed without conducting essential preoperative checks on his fitness for surgery. Post-surgery, complications escalated with the heart rupture, persistent bleeding, blood entering the lungs, and the progressive development of gangrene in the leg. Surprisingly, the patient was not referred to specialized treatment even as the medical condition worsened.

Throughout this , the doctors conducted a total of 14 surgeries, administered 42 blood units, pushing the patient to the brink of death. The negligence of the medical practitioners is evident as they did not intervene to prevent the issues from worsening, conducting experiments rather than employing appropriate measures. They failed to refer the patient promptly to an advanced medical center for specialized treatment, even though such facilities were available in Jaipur. It further noted;

"No explanation has been rendered as to why the foot of the Complainant from where the catheter was inserted for angioplasty as well as his heart continued to bleed, leading into emergency situations. When his heart ruptured and was bleeding continuously to alarming proportions, medicines were given to thicken the blood. He had PVD problem in his leg and despite that angioplasty was done. He was not put through the procedures of preoperative care to check his fitness for surgery. After the operation, the heart ruptured, and bleeding started and blood went into lungs and the gangrene in his leg kept increasing. Even then the Complainant was not referred for specialist treatment. When his blood was diluted, it was oozing out of the heart and when the blood was thickened, gangrene was spreading. Due to gangrene, foot started to blacken from below and then the leg had to be amputated up to knee, and later up to hipbone. The doctors did not even try to stop it and continued to experiment and conducted 14 operations and administered 42 bottles of blood and pushed him to the verge of death. The deficiency in service and medical negligence of the OPs are clear. The OPs repeatedly asserted in their arguments that when his heart was ruptured and bleeding, most important was to save his life. However, when gangrene was developing and two contradictory results were possible and both are likely to result in unacceptable damage to the patient, it was their duty to refer him to some advanced center in time for further specialist treatment, rather than continuing to experiment on him. Evidently, this was possible within and around Jaipur but the OPs failed to do so."

The Commission referenced similar cases, wherein, according to Jacob Mathew v. State of Punjab (2005) SSC (Crl) 1369, medical negligence refers to a breach of the duty of care, leading to injury or harm to the patient. This breach could be an act or omission in providing appropriate medical care. The doctors' gross mistakes in this case resulted in severe negligence. Even the delegation of responsibility to another doctor without the assurance of competency may amount to negligence.

Dr Laxman Balakrishna Joshi vs. Dr Trimbak Bapu Godbole & Anr AIR 1969 SC 128 outlined the duties of a doctor towards their patient: deciding to undertake the case, determining the appropriate treatment, and administering it with care. In this instance, the doctors failed on all these counts, leading to multiple failures in the treatment process. The Commission opined;

"A breach of any of the above duties may give rise to a cause of action for negligence and the patient may, on that basis, recover damages from his doctor. In the instant case, the OPs Doctors failed on all counts stated above due to multiple failures in the procedures and processes undertaken."

"In the instant case, the OP hospital is vicariously liable for the act of its doctors, who negligently treated the patient."

In Maharaja Agrasen Hospital vs. Master Rishabh Sharma & Ors, 2019 SCC Online SC 1658, the court established that a hospital is vicariously liable for the negligence of its doctors. Patients approach hospitals trusting their capability to provide proper care, and if this duty is not fulfilled, the hospital bears responsibility for the consequences. NCDRC observed;

"In our considered view, in the instant case OPs 2 (the doctor) & 3 (the cardiac consultant) were found wanting in all the counts as discussed in LB Joshi’s case (supra). It was not even bona fide mistake, but a therapeutic misadventure."

The Respondents' argument that the priority was to save the Complainant's life when the heart ruptured and bled, does not absolve them of negligence. Negligence continued as gangrene developed, and the patient's life was at risk. The doctors' failure to promptly refer the patient for specialized treatment was detrimental. The lack of thorough pre-operative checks and the insertion of the catheter into a leg suffering from PVD were clear indicators of negligence. It noted;

"In the present case, however, it is undisputed that the Complainant who had sought medical attention for tooth extraction, ended up in undergoing a total of 14 successive surgeries, administering of 42 units of blood, rupture to his heart, blood into his lungs, gangrene in the leg where the catheter was inserted, amputation and his leg up to the knee and further amputation up to the hip. As regards the contention pertaining to the stand of the State Commission in respect of option of open-heart surgery, the same was an observation, based on the version of the OP doctors themselves that, in the given condition of the blockages of the Complainant, open heart surgery was more appropriate and that it was the Complainant who had sought angioplasty as against open-heart surgery. As regards consent, after he was taken in for angioplasty, all along, he was in very critical state with imminent threat to his life. Thus, the consent that was obtained was without scope for any informed deliberations and making decision. It was rather without option to him or his relatives. As regards allegation of medical negligence, evidently the critical pre-operative checks to determine his suitability to undergo the surgery were not carried out. This failure was discovered after completion of angiography when continuous bleeding was noticed from the leg where catheter was inserted. Only then it was discovered that he was suffering from PVD, and further complications emerged as a sequel. In addition to the insertion of catheter from the leg to patient suffering PVD, the negligence is also conspicuous as this procedure further resulted in rupturing his heart, profuse bleeding, accumulation of blood in lungs, loss of sensation to his leg and infection. Ultimately, this led to gangrene, 14 surgeries and amputation of his right leg first to the knee and thereafter up to the hip. Even when the patient was in critical distress, the OPs continued with experimental procedures, instead of promptly ensuring more seeking specialized medical attention. It jeopardized his safety. Therefore, medical negligence is conspicuous even to the naked eye."

Regarding the quantum of compensation, the national consumer body said that quantum of compensation must follow the principle of 'restitutio in integrum' as per Malay Kumar Ganguly vs. Sukumar Mukherjee and Ors. A just and adequate compensation should cover financial losses, future medical expenses, and the pain and suffering endured by the victim. The court should aim for consistency in compensation awards for similar cases to ensure fairness.

Subsequently, the learned State Commission's decision to award compensation to the Complainant was held just and fair. The Commission noted;

"While the learned State Commission awarded compensation to the Complainant, in his Appeal he disputed the adequacy of the same and argued that it does not adequately account for the extent of his disability, pain and the suffering he endured. Instead of being a support to his family, he has become a liability at this age itself. He needs to secure his future and, therefore, he needs to be adequately compensated. On the other hand, in their cross-Appeal, the Opposite Parties raised several issues, including disputes over consent, absence of medical negligence, non-seeking of expert medical opinion and proportionality of compensation awarded. Challenging the findings of the learned State Commission, the OPs emphasized that they acted in his best interest and that the State Commission should have sought expert medical opinion. They also contested the amount of compensation awarded, asserting that it is excessive and not in line with established legal principles. The primary issues as to whether the OPs who treated the Complainant are correctly held liable for medical negligence is already addressed above. Considering the facts and circumstances of the case, the compensation awarded by the learned State Commission to the Complainant is just and fair."

Both appeals were dismissed by NCDRC, affirming the compensation awarded by the State Commission as just and appropriate. NCDRC held;

"Based on the discussions above, the Order of the learned State Commission in CC No. 157/2017 dated 30.07.2019 is upheld. We also hold that the compensation awarded to the Complainant by the learned State Commission is just and fair and, therefore, the same is affirmed. Both the Appeals are, therefore, dismissed."

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