Lack of Standard Care to High-Risk Patient Before and After Surgery: NCDRC Upholds Rs 25 Lakh Compensation order Against Max Hospital, 3 doctors

New Delhi: The National Consumer Disputes Redressal Commission (NCDRC) recently upheld the Punjab State Commission's order directing Mohali-based Max Hospital and its 3 doctors including a senior cardiologist, to pay Rs 25 lakh compensation to a man for not providing a standard of care to his wife before and after conducting the Bilateral Total Knee Replacement Surgery.

It was observed by the Commission that the woman was a high-risk patient and the ECHO test conducted a day before the surgery showed LVEF as 35%. Therefore, it was a cardiac risk, noted the Commission and observed that after discharge, when the patient's condition deteriorated, the hospital did not admit her. 

"The lack of standard of care provided at both the occasions in one operation constitutes medical negligence on the part of the hospital and the doctors and the senior cardiologist," stated the Commission.

The history of the case goes back to 2014 when the complainant's wife was suffering from knee pain and she visited the Mohali-based treating hospital for a check-up. The treating doctors informed that the patient had advanced osteoarthritis and suggested Bilateral Total Knee Replacement surgery and placing a rod in the patient's right leg. Accordingly, the surgery was conducted on 20.08.2014.

On 23.08.2014, the patient's condition deteriorated and she was shifted to ICU  and later to SICU where she was kept on a ventilator till 08.09.2014. Thereafter, the treating doctor referred her to Cardio Dr. Saxena in CCU and an Angiography test was conducted. Since the report came out to be normal. the patient was discharged despite her critical condition. On 11.09.2014, the patient became very critical at home and allegedly, even when the patient was taken to the hospital, the doctor refused to admit the patient back. Finally, the patient was admitted to SGHS Hospital, Sohana, where the patient remained in ICU till 23.09.2014 and later was put on a ventilator. However, unfortunately, the patient died on 01.10.2014.

The complainant submitted that pre-operative tests were conducted before the surgery. Dr. Gupta conducted Echo Test and as per report, left ventricular Ejection Fraction (LVEF) was recorded to be 35%. The complainant contended that as per the medical jurisprudence, the doctors are not supposed to conduct Knee Replacement Surgery on a patient with 35% LVEF as otherwise, the surgery could be fatal for the patient.

However, despite this, the doctors allegedly conducted 2D Color & Doppler Echocardiography test on the same day and the reports showed LVEF was 60% which was medically impossible. The complainant alleged that this was manipulated and doctored by the treating doctors to conduct the surgery against the patient's health condition.

It was also alleged that the surgery was conducted without consulting the X-ray reports of the knees and chest of the patient. The reports allegedly showed Cardiomegaly, a state where Cardiac of the deceased was shown as enlarged.

The complainant alleged that the patient was not provided care as per medical protocol before and after the surgery. She got infection/sepsis and remained on invasive mechanical ventilator for approximately one week. It is also alleged that the death summary report also showed that the patient had swelling in both the knees. Hence, alleging medical negligence on the part of the hospital, the doctors and the senior cardiologist, the complainant filed a complaint before the State Commission.

On the other hand, the hospital and doctors submitted that all the pre-operative tests were conducted and after fully confirming that the patient was fit to undergo surgery, clearance for conducting surgery was given by the concerned doctor. It was also stated that the complainant's contention that the LVEF was only 35% was totally incorrect as 2D Colour and Doppler Echo done on 19.08.2014 clearly showed the LVEF of the patient was more than 60% which was within the normal parameters.

Further stating that the patient was not having any complaints of breathlessness or chest pain, the hospital and doctors claimed that there was no negligence on their part.

While considering the matter, the State Commission allowed the complaint and directed the hospital and doctor to pay Rs 25 Lakh as compensation to the complainant, along with interest at the rate of 8% per annum from the date of filing the complaint. The Commission also directed them to pay Rs 33,000 as litigation costs.

However, the State Commission's order was challenged by the hospital, its director and the Head of Cardiology Department. Another plea was filed by a senior cardiologist who also prayed to NCDRC to set aside the State Commission's order.

After perusing the documents the NCDRC bench noted that the ECHO report of 19.08.2014 showing LVEF as 35% was a correct report. On the other hand, while addressing the complainant's contention that the report of the 2D Colour & Doppler Echocardiography was fabricated, the Apex Consumer Court noted that the hospital and the doctors failed to produce any requisition or any bill to show that the said test was conducted.

"Therefore, the report of 2D Colour & Doppler Echocardiography cannot be accepted," held NCDRC.

Perusing the ECHO Test report dated 19.08.2014, the Commission noted that LVEF was 35% on 19.08.2014 i.e. one day before surgery. "As mentioned by the complainant, as per the medical jurisprudence, Bilateral Total Knee Replacement (BTKR) is not advisable and the doctors are not supposed to conduct Knee Replacement Surgery of the patient when LVEF is 35%. The appellants have filed three documents on LVEF. The first explains LVEF in detail and as per that LVEF between 30 to 40% is categorized as moderately abnormal. The second is three successful case study of three geriatric patients with low LVEF who underwent total knee replacement under combined spinal epidural anaesthesia. The third is an article on the America Society of Anaesthesiologists physical status classification," noted the Commission.

"In this case, the appellant has not controverted the assertion that conducting a surgery with LVEF of 35% is not advisable. Further, it has not been clarified if the operation was done under general anesthesia or spinal anesthesia to be covered by the case studies submitted," it further observed. 

The Commission also perused the X-ray of knee and chest reports and noted that those reports were prepared on 21.08.2014 and 22.08.2014 whereas the surgery was conducted on 20.08.2014. "Therefore, it is apparent that the surgery was conducted without seeing the reports and no evidence has been brought on record to substantiate the claim that the reports were shared with surgeon prior to the operation," noted the Commission.

Additionally, the Apex Consumer Court also relied on the expert opinion dated 17.03.2016 of the medical board constituted by the Medical Superintendent, PGIMER, Chandigarh. The report stated, "As per available records patient was a high risk case for any major surgery / detailed preoperative evaluation and risk stratification was required."

"Patient was discharged in stable and satisfactory condition as per available records. However when patient reported next day she should have been admitted, evaluated and managed as per their hospital protocol," further mentioned the expert report.

Relying on the expert opinion, the Commission noted,

"It is seen that the expert opinion states that the patient was a high risk case for any major surgery and detailed preoperative evaluation and risk stratification was required. It is clear that the same was not done, as no evidence of the same is on record. It is also to be noted that when the patient had come to the hospital in an emergency, she should be admitted, evaluation and managed as per their hospital protocol. The version of the hospital that the patient was found to be normal when she came to the hospital in an emergency cannot be accepted because immediately thereafter the patient was admitted in ICU in Sohana and ultimately died."

While considering the matter, the Commission noted that the Senior Consultant Cardiologist at the hospital Dr. Sharma submitted that he was a Cardiologist and had nothing to do with the pre-operative assessment or of the surgery done on the patient, and therefore, he should not be held liable. However, the Commission noted at this outset,

"It is seen that the patient had LVEF of 35% and it was a cardiac risk. Further, when after surgery the patient’s condition deteriorated she was shifted to the cardiology department on 09.09.2014 and she was discharged from there on 10.09.2014. In view of the same, as the patient was under the direct care of the cardiology department post operation for 09 days, Dr. Sharma cannot claim that he has no liability."

Therefore, the Apex Consumer Court upheld the Rs 25 Lakh Compensation granted by the State Commission and mentioned in the order,

"In this case, we are of the view that the standard of care in a high risk patient at the pre-operative stage was not provided, as also noted by the medical board. Further, when she was brought back in a critical condition, the hospital should have admitted her and acted as per medical protocol. The lack of standard of care provided at both the occasions in one operation constitutes medical negligence on the part of the hospital and the doctors and the senior cardiologist."

"In view of the above discussion, we are of the opinion that the State Commission has passed a well-reasoned order, which does not require any interference by this Commission. Therefore, the both the appeals are dismissed. All pending I.A., if any, shall stand disposed of," it further observed.

To view the order, click on the link below:

https://medicaldialogues.in/pdf_upload/ncdrc-upholds-rs-25-l-compensation-240749.pdf

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