Issue of Specialist Degrees comes before NCDRC during medical negligence case, Forum gives relief to Gynaecologist, MBBS doctor

Presiding Member of the Commission, S M Kantikar and Member, Binoy Kumar concluded that there was no dereliction of duty of care and the decision of the Gynaecologist to perform emergency Subtotal Hysterectomy was correct.

The case concerned a patient who was under the observation of the Gynaecologist at her hospital (Jha Hospital) during her first pregnancy. After Ultrasonography (USG) study it was diagnosed as twin pregnancy. It was alleged that the doctor informed the patient about need for Caesarean instead of a normal delivery. She performed the caesarean operation under spinal Anaesthesia administered by the anaesthetist. After the C-section, the patient was allegedly bleeding heavily, but no steps were taken by the doctor to stop the bleeding. Resultantly, the patient suffered from severe Post-Partum Haemorrhage (PPH). Her abdomen became distended, and she was taken to OT again for hysterectomy. It was allegedly performed without the consent of the patient's kin.

The complainants (the patient, the patient's husband and her father-in-law) alleged that due to heavy dosage of spinal anaesthesia, the uterus did not contract fully after delivery, thus caused PPH. "It was wilful negligence of the doctor and anaesthetist, who did not check full contraction of uterus before putting the stitches. It further resulted into placental fragments and blood clots being left inside the uterine cavity. The several open sinuses at placental side led to heavy bleeding. The surgeon might have injured the uterine artery during the caesarean," they added.

They took opinion from few expert doctors and came to know that the doctor committed fraud in her qualification -degree DGO which was not recognised by MCI. The anaesthetist who is the husband of the doctor was not a qualified Anaesthetist and/or Radiologist but he was just MBBS. The degree ’MA’ mentioned in his letterhead was misleading as Master of Anaesthesia. The Anaesthetist performed USG of the patient and also gave spinal anaesthesia. The third name of a doctor on the prescription was mentioned to mislead the or only to deceive the patient as he never visits Jha Hospital and his whereabouts nobody knows. Thus, it was only to cheat the patient.

Being aggrieved by the alleged negligence of the doctors, the Complainants filed the Consumer Compliant under section 21 of the Consumer Protection Act, 1986 against them for medical negligence and deficiency in service seeking compensation to the tune of Rs. 45,00,000/-.

However, denying the allegations of medical negligence, the hospital and the doctors submitted that the anaesthetist did not administer Anaesthesia, but it was administered by another Anaesthetist, MBBS, DA. moreover, the Caesarean Section was done by the Gynaecologist in the presence of another doctor who was called because of high-risk status of the patient. The two babies were delivered and handed over immediately to a paediatrician.

Thereafter, as soon it was confirmed that massive PPH and Atonic Uterus, as the patient was not responding to aggressive conservative management, therefore she was immediately shifted to OT. The doctors in the OT reassessed the patient’s condition, confirmed there was no trauma to her genital tract. The team of doctors in OT, took a decision of emergency hysterectomy - to remove the Atonic Uterus i.e. Caesarean Hysterectomy.

The patient’s attendants were kept informed at every point, wherever necessary, and whenever enquired. They performed subtotal hysterectomy. The patient was continued on the Oxytocin Drip and additional injections of Prostodin (250mcg). In addition vasopressors besides Colloid and Crystalloid solutions were also administered. The relatives were kept informed time to time.

Further addressing the issue of her qualification, the Gynaecologist submitted that she never ever stated that her husband possessed highest degree in Anaesthesia as ‘Master of Anaesthesia’- MA which is the highest degree in anaesthesiology. However, he was attending as a General Physician. The degree of MA was for Master of Arts in Psychology conferred him by Agra University in 1984. He did not administer Anaesthesia to the instant patient. Before MCI, the Complainant had not taken such ground, thus it was an afterthought allegation.

After hearing the submissions, the court observed that in medical parlance there is no such degree “Master of Anaesthesia” it would be either degree M.D. or diploma D.A. The complainants have intelligently twisted the words and filed the instant complaint. Displaying the degree on his letterhead or display board in the clinic or hospital does not constitute professional misconduct. The Commission said;

"In our view, it was neither a fake degree nor any misrepresentation by the anaesthetist. But, mentioning as physician and heart specialist shall not be allowed without valid degree or diploma as prescribed under MCI (now National Medical Commission (NMC))."

About the treatment, the Commission did not find any fault with the treating doctors, because it was twin Pregnancy with Premature Rupture Of Membranes (PROM). It said;

"She had PIH and one baby showed signs of Foetal Distress. Therefore, the Gynaecologist performed C-section under spinal anaesthesia and the patient delivered twins a male and a female. Thus, Caesar was performed in the best interests of the mother and twins. Thereafter due to PPH the patient was in haemorrhagic shock. The patient was shifted to the OT and emergency Subtotal Hysterectomy was performed. Thus in our considered view, the decision of Gynaecologist was correct, there was no dereliction of duty of care."

The apex consumer body further observed that the sequence of events revealed that the patient was primi gravida with Twin Pregnancy. It noted;

"On the USG findings in second trimester, it was high risk pregnancy. The patient developed Jaundice, she was examined by the anaesthetist again informed of high risk pregnancy and referred her to Agra for opinion from Dr Barun Sarkar a senior OBG , but the Complainants have not filed treatment papers. The patient was increasingly irregular and asked to seek a second opinion, but she emphasized her faith in the treatment of the Gynaecologist and the anaesthetist. On 23.09.2001, she advised admission and trial for normal labour, but she did not follow the advice, got admitted on 27.09.2001. After the C- section she developed PPH due to Atonic uterus. Blood Transfusion was started at 1.15 P.M. The attendants were informed of the surgical possibilities; the husband opted for Hysterectomy and gave his consent. Sub-Total Hysterectomy was performed under GA and Blood Transfusions were given. The patient was well oriented, conscious. 2nd unit of blood started in O.T. The patient was sifted to room at 4.30 pm. The 3rd and 4th unit of blood was transfused in the room. Oral intake allowed on 29.09.2001 at 10P.M. She was discharged on 07.10.2001 with follow-up instructions with her two babies."

It further clarified on the reason for PPH as;

"In our view, the PPH was due to Atonic uterus. It was not due to any retained placental pieces. As a standard of practice after Cesarean delivery, the placenta as well as its membranes are removed manually and the uterine cavity is cleaned by suction & mopping. Therefore, no possibility of any placental fragments or its membranes being left behind within the uterus. The Uterus was firmly contracted, therefore chances of retained fragments does not arise. Also, bleeding due to retained small placental fragments is uncommon in the immediate postpartum period. The late PPH occurs after 24 hrs or more after delivery and in that case the most common causes are retained fragments of placenta and sub involution of the placental implantation site. In the instant case the bleeding was started at about only one hour after her delivery."

Focusing on the main issue that whether emergency hysterectomy performed by the Gynaecologist was not correct, the Commission remarked that it should be borne in mind that a doctor faces emergency situation he/she has to choose the treatment to save the patient. It referred to the Jacob Matthew v. Union of India [3], Hon’ble Supreme Court observed as under:-

"25......At times, the professional is confronted with making a choice between the devil and the deep sea and he has to choose the lesser evil.

NCDRC eventually dismissed the complaint stating that the Complainants have failed to establish failure of duty of care or any deficiency from the treating doctors. It held;

"In our considered view, the Gynaecologist and the anaesthetist have attended the patient with due care, skill and diligence as acceptable to the medical profession. There was no medical negligence on the part of the Opposite parties. The skill of the doctor differs from each other as there may be more than one course of treatment which may be advisable for treating a patient. Thus, as long as the doctor performs his duties to the best of his ability and with due care and caution, negligence can’t be attributed to him."

To view the original order click on the link below: