Lack of Pre-operative Management before Retrograde Pyelogram, Ureteroscopy: Max Hospital, Surgeon told to pay Rs 2 lakh compensation
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Chandigarh: The State Consumer Disputes Redressal Commission, Punjab has recently held Mohali-based Max Super Specialty Hospital and its surgeon guilty of medical negligence while performing Retrograde Pyelogram (RGP) and Ureteroscopy (URS) surgery upon a patient, whose ureter got damaged in the process.
Such a decision was taken by the State Consumer Court as it took note of the fact that the hospital and the surgeon Dr. Rai, withheld pre-operative investigations and conservative management record, which was required before the operation. Further, the pre-operative consent had also not been taken by them.
Taking note of the fact that the patient was suffering from fever during admission, the Commission observed, "Due to inflamed issues, there were chances of manipulation intervention and that enhances the risk of complication. It was incumbent upon the OPs that if there was infection and inflammation, to have treated the patient conservatively to control the infection and inflammation first, before proceeding to operate upon the patient."
The history of the case goes back to 2019 when the complainant suffered pain in the right side of the abdomen and approached Shri Dhanwantry Ayurvedic College and Hospital, where USG was conducted. A stone was found in his ureter on right upper side and impressions of Bilateral renal concretions and Grade II fatty infiltration of liver were also mentioned in the said USG report.
Thereafter, he got admitted to Max Super Specialty Hospital, Mohali. After conducting various tests, the patient had been diagnosed with Upper Ureteric Calculus.
It was alleged by the complainant that the hospital and the doctor did not conduct any test to locate the position of the stone in the ureter. Following this, the surgeon of the hospital, Dr Rai performed Retrograde Pyelogram (RGP) and Ureteroscopy (URS) surgery. The physician injected a radiocontrast agent into the ureter in order to visualize the ureter and kidney with fluoroscopy or radiography in a urologic procedure i.e. Retrograde Pyelogram.
It had also been alleged by the complainant that the hospital and doctor recorded that the ureteroscope could not be negotiated beyond mid-ureter, so on withdrawing back the scope from ureter, which suddenly gave way and suspected to be avulsed.
He further alleged in his complaint that the ureter was injured from two sides while withdrawing the scope from the ureter. Further it had been alleged that the hospital and doctor abandoned the procedure due to said reasons and performed nephrostomy and wound was closed leaving the tube drain.
Although the complainant had been informed that for repair of the damaged ureter, an attempt was required to be made, he alleged that no corrective surgery was performed and the complainant was discharged on 28.05.2019 with urine collection bag.
He was asked to come for a follow up after seven days and the discharge summary mentioned that "a plan would be for ileal ureter replacement after 3 months", which was a reconstruction of urinary tract.
Besides, the complainant also alleged that before conducting the said surgery, no X-ray of abdomen and USG was conducted by the hospital and doctor, which has resulted into injury.
Following this, the complainant approached the Postgraduate Institute of Medical Education and Research, Chandigarh (PGIMER), where his injured ureter was recreated after taking a piece from small intestine of the complainant.
Claiming that he had to suffer physically and mentally, the complainant claimed a compensation of Rs 20 lakh along with Rs 1 lakh for litigation expenses.
To support his allegations, the complainant filed his affidavit, and he also submitted several evidence including the copy of the ultrasound report, discharge summary of Max Hospital, bills, medical record at PGIMER etc.
The counsel for the complainant submitted that there was rupture at two places while conducting the surgery. He also claimed that in order to get rid of the complainant and save their skin, the hospital and the surgeon allegedly left the patient in pain and discharged him with catheter.
On the other hand, the hospital and the surgeon submitted that the complainant had been admitted with high fever and his USG report reflected the position of stones. Therefore, they argued that no further investigation was required. They also claimed that the hospital and the doctor performed retrograde pyelogram to confirm stones and the patient was operated with utmost safety and all precaution by adopting URSL or Uretoscopic lithotripsy, which is most effective by adopting minimal procedure for the patient.
It was their argument that the unfortunate situation arose, not due to lack of any skill or competence of the Doctor/s or proper care but because of inflammation, which had occurred due to chill fever and pain for days. The report also reflected that stones were tightly encapsulated due to inflammation and granulation issue and as such, while retracing the said avulsion had occurred, for which complainant was advised for follow up, they contended.
Further, they pointed out that even in PGI Laparoscopic Surgery was planned but it was converted into open surgery. Therefore, the procedure adopted by the concerned doctor was not contrary to any medical journal.
After taking note of the submissions by both the parties and also going through the medical record, the Consumer Court noted, "The sequence of events clearly proves that the complainant had approached OP No.1; by relying upon the report of USG Exhibit C1, OPs proceeded to operate the complainant. On the basis of Exhibit C-2, the complainant was advised CBC (Complete Blood Count) besides other tests. However, the OPs handed over all the reports to the complainant except CBC (Complete Blood Count). If the OPs had produced the CBC report, it would have exposed them that there was infection coupled with inflammation due to which, there were possibilities of complication."
"Due to inflamed issues, there were chances of manipulation intervention and that enhances the risk of complication. It was incumbent upon the OPs that if there was infection and inflammation, to have treated the patient conservatively to control the infection and inflammation first, before proceeding to operate upon the patient. This appears to be the only reason why OPs have withheld the CBC report. Though avulsion is a rare complication; however, this could have been avoided. The fact that the patient had infection and consequent inflammation finds support from the discharge summary Exhibit C-3, prepared by OPs," further noted the court.
Opining that the complication in the surgery could have been avoided, the bench noted,
"Despite this, the OPs instead of adopting conservative treatment to control the infection, rushed to operate the patient to avoid losing patient. The OPs admitting inflammation to be the cause of narrowing the passage of ureter which further led to avulsion while retracting. This complication could have been avoided, had the OPs instead of rushing to operate initially adopted, conservative treatment."
Therefore, holding the hospital and the surgeon guilty of medical negligence, the order mentioned,
"The OPs withheld the pre-operative investigations and conservative management record, which was required before operation. OPs had also withheld this pre-operative consent of the complainant or his family members and only brother was informed about the complication, as wife was not available. It is mandatory requirement of medical procedure that unless the situation is so emergent that there is threat to the life of the patient and it is not possible to wait for the consent that the doctor can operate without waiting for the consent. Otherwise, pre-operative consent is mandatory which has not been obtained by the OPs for reasons best known to them, as to why the OPs had to proceed with the surgery without pre-operative consent as well as high risk consent. From this, the negligence of the respondent stands fully established."
The State Commission also referred to the Supreme Court's judgment in the case of V. Kishan Rao v. Nikhil Super Specialty Hospital, where it had been held by the top court that in a case where negligence is evident, the principle of res ipsa loquitur operates and the complainant does not have to prove anything as the thing (res) proves itself.
Referring to this judgment, and also considering the pain and suffering of the complainant, the consumer court allowed the complaint and awarded Rs 2 lakh as compensation to the complainant along with Rs 15,000 for litigation expenses.
To read the case order, click on the link below.
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