Madras HC Slaps Rs 2 Lakh Compensation on State for Sub-par post-operative treatment after Appendectomy

Chennai: The Madras High Court bench recently directed the State Government to pay Rs 2 lakh compensation to a woman whose son allegedly received sub-par post-operative treatment and care at the Government Hospital, Mettur, after undergoing an appendectomy.

Following the surgery, the child developed Enterocutaneous fistula and had to be taken to other hospitals for further treatment. The Court noted that, "Had there been sufficient attention devoted and timely intervention, there is a possibility that the complications may have been arrested/controlled or avoided altogether."

Concluding that the tertiary care system in the State was responsible for the medical trauma of the child, the HC bench comprising Justice Anita Sumanth noted, "The bout of rectal bleed at the initial instance (cause not explained by the Committee) and the Enterocutaneous fistula which is defined as Iatrogenic indicate that the post-operative treatment and care was sub-par leading to the inference that the system, as a whole, failed the child."

Apart from granting the compensation, as a measure of securing the patient's ( 22-year-old now) future, the court also directed the District Collector to recruit him to a suitable post.

The matter goes back to 2016 when the child complained of stomach pain and was taken to Mettur Government Hospital for treatment. A doctor at the hospital advised for an emergency appendectomy and the child was admitted as an in-patient. According to the petitioner, the surgery was conducted without obtaining any consent and the consent was obtained from the grandfather of the child, who was in attendance with the child at that time.

Post surgery, the child was transferred to the Intensive Care Unit (ICU). During the stay in the ICU, the petitioner noticed bleeding in the stools and the child complained of constant pain. Even after the child was discharged, he continued to complain of constant pain. Thereafter, a scan was taken in a private hospital which revealed formation of puss in the stomach and thus the child was admitted to Salem Mohan Kumaramangalam Government Hospital. On the same day, the petitioner filed a complaint before the Inspector of Police.

Thereafter, a laparoscopic surgery was performed. However, allegedly, despite the surgery, the child's condition did not improve. Since the doctors there advised yet another surgery, the child was shifted to a hospital in Erode and thereafter to GEM Hospital, Coimbatore, where he was treated for about 15 days. 

Approaching the HC bench, the petitioner sought reasonable compensation, interim compensation of Rs 2 lakhs enhanced to Rs 30 lakhs and appropriate action taken against the doctor of Government Hospital Mettur.

The court noted that all the pleadings were specific only to the treatment in Mettur GH. It also observed that after receiving the complaint by the petitioner, the Joint Director of Health Services had appointed Dr. Senthilkumar, Medical Officer and Dr. Elabarasi, Assistant Surgeon as enquiry officers. Due and careful enquiry was conducted and an enquiry report was submitted after capturing the facts. The enquiry concluded with the endorsement that the surgery was done properly with utmost care having been given to the child.

Meanwhile, the Superintendent of Police stated in his counter that after receiving the complaint filed by the petitioner to take appropriate action against the allegation of medical negligence, the complaint was forwarded to the jurisdictional Inspector of Police at Mettur Police Station, Mettur Sub-Division, Salem District. A preliminary investigation was carried out as directed by the Hon’ble Supreme Court in the case of Jacob Mathew (supra). The medical opinion that was received did not contain any finding of negligence on the part of the doctor at Mettur GH.

The doctor against whom the allegation of medical negligence was targeted denied all allegations of negligence. He submitted that after admission of the child, he noticed the need for emergency surgery and obtained consent from the grandfather and performed an appendectomy on the child on the same day. He claimed that he left the theatre only after the child regained consciousness and after ensuring that the surgery had taken place uneventfully. As per normal procedure, the child was shifter to the post operative ward.

He further stated that the child did not adhere to the instructions of the ward staff to take complete bed rest. According to him, the child walked up and down the ward straining himself which is the reason for the complication of dysentery. When informed by the ward staff, he immediately shifted the child to the ICU. Thereafter, he stated that the child was shifter to the regular ward on 31.10.2016. He further claimed that even though the child was instructed to return after 8 days for removal of stitches, he did not return.

Further, he referred to the feedback given by the petitioner at the time of discharge endorsing the good treatment as well as the conclusions in the enquiry conducted by a two member committee which were in his favour. He relied on a decision in the case of Smt. Gunwant Kaur And Ors. vs Municipal Committee, Bhatinda to argue that professionals such as Doctors can be prosecuted only if their treatment is established to be rash or negligent.

While considering the matter, the Court noted that the child was in ICU till the date of discharge and he was not transferred to the general ward as per general practice. Later, the child was admitted first to a private hospital and then to Salem GH. In light of medical opinion to proceed for laparoscopic surgery for draining the abscess, the child was kept under observation and was treated conservatively till 10.11.2016, when he was operated.

On 13.11.2016, the child was found to have oozing from the site which included feces. The diagnosis was post appendicectomy Enterocutaneous fistula. After obtaining necessary medical opinion, the child was under conservative management of the fistula on 14.11.2016 and 15.11.2016. Then he was discharged against medical advice from Salem GH and was admitted in GEM Hospital on 17.11.2016 and was discharged on 30.11.2016.

Meanwhile, during the proceedings, the State informed the Court that an Adhoc Committee had been constituted. The committee called upon the petitioner and the child on 22.08.2023, caused enquiry on the accused doctor on the same day and submitted a report stating, "The treatment given by the 10th respondent has been appropriate and the patient did, not turn up for follow up to him. Enterocutaneous fistula is a known but rare complication of appendicectomy which was managed appropriately at two higher centres, one government and one corporate. The child is currently healthy with no morbidities and hence no gross negligence or misdiagnosis or inappropriate treatment has been made out in this case."

However, the court was dissatisfied with the report and passed an order on 06.10.2023 calling for a supplementary report. The State requested to include the head of the Department of General Surgery of Madras Medical College as well in the committee and therefore, the Committee was reconstituted.

The new panel noted that the patient had developed enterocutaneous fistula post-appendicectomy. However, the Committee stated that the medical treatment was adequate and no negligence on the part of the treating government doctors was observed since the patient was operated on the day of admission and the necrosed appendix was removed. However, the patient failed to come back for review which would have hastened the clearance of the infection from the abdomen and ensured early recovery, opined the panel.

Further, perusing the case sheet of Salem Medical College, the panel noted that the treatment there was as per established protocols and adequate care was taken to ensure a safe outcome. The time period of four days in Govt. Salem Medical College was spent in stabilizing the patient so as to ensure a safe outcome of the second surgery.

Taking note of the Committee report, the HC bench noted, "The sum and substance of the report is there has been no negligence by the professionals. The Report notes the presence of infection at the site and states that had the child returned for a review as required, the same could have been attended to appropriately. The Committee specifically states by way of a note in conclusion, that Enterocutaneous fistula is a communication between intestine and skin which is not an uncommon complication of gastrointestinal surgery."

The Court observed that Mettur Government Hospital is an upgraded Primary Health Centre and lacks necessary medical equipment such as equipment to take an ultrasound or scan. It also noted that even though normally cases requiring surgery or advanced treatment are referred to the nearest Government Hospital, in this case, the child had to be subjected to emergency surgery, which according to the experts was the right decision.

However, the bench noted that the bout of rectal bleed was not really explained by the Expert Committee except to state that the child was administered IV and blood transfusion after which the patient stabilized. At this outset, the court noted, "The Court is thus unaware as to what could have caused the bleeding."

"The Enterocutaneous fistula, is explained by the Expert Committee to be a complication not uncommon to gastrointestinal surgery. The most common cause of Enterocutaneous Fistula (source: website of National Library of Medicine (National Center for Biotechnology information) – Authors Kevin B Cowan; Sebastiano Cassaro) is stated to be iatrogenic, occurring in the postoperative period. The term ‘iatrogenic’ is defined in (Merriam Webster Dictionary Thesaurus) as induced unintentionally by a physician or surgeon or by medical treatment or diagnostic procedures. Medical opinion thus points to Enterocutaneous Fistula to be a result of improper surgical intervention," the Court noted.

The HC bench observed that the version of events put forth by the doctor, hospital and authorities does not entirely convince the Court that the threshold for care, overall, have been met satisfactorily. While the bench noted that the Expert Committee's report stated that the traumatic events suffered by the child were not uncommon complications post an appendectomy, the Court was not convinced that the child received optimum care from the General Hospitals.

Opining that the post-operative treatment and care was sub-par, the Court observed, "Had there been sufficient attention devoted and timely intervention, there is a possibility that the complications may have been arrested/controlled or avoided altogether. The petitioner has taken a video of the child in the ICU post the D-lap in Salem General Hospital. The footage reveals faecal matter oozing from the site of the surgery. One thing is crystal clear. The infection in the surgical site had been left to fester far too long without proper attention. The bout of rectal bleed at the initial instance (cause not explained by the Committee) and the Enterocutaneous fistula which is defined as Iatrogenic indicate that the post-operative treatment and care was sub-par leading to the inference that the system, as a whole, failed the child."

The bench observed that the child continued to be sick after discharge, thereafter sought treatment at a private hospital, and after some suffering was admitted at Salem GH. The Diagnostic laparoscopic surgery (D-lap) was conducted on 10.11.2016 after conservative management of the infection. The child was then discharged against medical advice and was admitted in a private hospital.

Noting these factors, the Court observed, "The narration of events informs me sufficiently to conclude that the tertiary care system in the State is undoubtedly responsible for the medical trauma that the child was put through."

Therefore, the bench granted Rs 2 lakh compensation to the petitioner and directed the State to remit the amount to the bank account of the child. It ordered, "As a measure of compensation, the State is directed to pay the child a sum of Rs.2,00,000/- (Rupees two lakhs only) to be remitted to the bank account of the child (to be obtained by R1 from the petitioner) within a period of six (6) weeks from today." 

Further observing that the child is now aged 22 years and has registered with the District Employment Exchange, the Court, as a measure of securing his future, directed him to furnish the details of his qualifications and employment registration to the District Collector along with an application for appropriate employment.

"Mandamus is issued to the District Collector/R2 to consider the application of the child and recruit him to a suitable post, subject to his being qualified for the same. Let this process be completed within a period of three (3) months from his making a requisition before R2," ordered the High Court.

To view the order, click on the link below:

https://medicaldialogues.in/pdf_upload/madras-hc-medical-negligence-237856.pdf

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