Max Super Speciality Hospital absolved of medical negligence, told to pay Rs 1 lakh compensation for administrative lapses

Presiding Member of NCDRC, Dr SM Kantikar strictly cautioned and directed the hospital to take necessary steps for systemic improvement.

The case was filed by Delhi-based Mohit Jain against the Hospital, two doctors, and a haematologist. In April 2015, he was admitted to Max Super Speciality Hospital where Immune Thrombocytopenic Purpura (ITP) was diagnosed and hemolytic anemia was reconfirmed. He paid Rs16 lakh for his medical treatment.

The main allegation of the patient was a failure to detect the presence of schistocytes in the peripheral blood smear (PBS), which resulted in delayed diagnosis of micro-angiopathic hemolytic anaemia (MAHA) and its treatment. He contended that the doctor recorded the presence of 25 nRBC on PBS but the presence of schistocytes was totally ignored. He alleged; "It was gross negligence and case of res ipsa loquitur as not following the standard operating procedures (SOP)."

In his complaint, he claimed that the discharge report was incorrect in facts, vague and misleading. It was sub-standard, which lacks crucial details, and did not give a clear and accurate progression of the patient's condition and treatment. For a long time, he says, he was under the follow-up of a neurologist, at the Hospital, who put him on anti-epileptic drugs for six months and medication for anxiety regularly, which he was consuming even while filing his complaint with the NCDRC.

He further alleged that when he was diagnosed with a blood problem (haematology), the doctor should have immediately transferred him from medicine to haematology and it was not done in spite of his several verbal and written requests even marked as 'urgent'.

In June 2015, the complainant approached the Chief Minister (CM), deputy CM and health minister of Delhi. He also approached various government authorities like DHS and Delhi Medical Council (DMC). He further alleged that the Hospital and doctors did not cooperate with the government authorities and had not filed medical records.

"The DGHS, in its report mentioned that the hospital and doctors were found indulged in unethical practices. The copy of report was sent to DMC but the DMC passed non-speaking Order on medical negligence. The Complainant challenged the DMC Order by filing Appeal before the Medical Council of India (MCI). After huge delay, the hospital provided voluminous medical record about 657 pages to him. The records were alleged to be different from those placed before the Govt. authorities. Therefore, fabrication, manipulation, interpolation of the medical record by hospital and the doctors cannot be ruled out. The hospital and the doctors failed to make differential diagnosis of TTP. There was no family history of TTP, but doctors told about the risk of inheritance to their children, therefore he and his wife (couple) suffered severe mental anguish and trauma," the complainant submitted.

The Complainant raised the allegations of administrative issues, functioning of hospital, billing and malpractices. Being aggrieved, he filed the instant Complaint before the Commission, seeking overall compensation to the tune of Rs. 20,33,44,867/-.

In response, before the Commission, the Hospital submitted that the immune thrombocytopenic purpura (TTP) diagnosis was made on 20 April 2015. It submitted.

"The duration of treatment for such patient depends upon the condition of the patient. Initially, five-six sessions of PEX were planned but since the platelet count was gradually increasing, the treatment plan was revised and 12 PEX sessions were carried out as lifesaving measure. The patient was treated with standard protocol. He was discharged in good condition on 4 May 2015. Mr Jain himself acknowledged that he did not suffer repeat episodes."

The establishment further submitted that the DMC observed that the diagnosis seems to have been arrived at in a reasonable period and managed the patient, and the DMC has already held that no case of medical negligence was made out. The hospital and the doctors also denied tampering with the records.

On the other hand, taking cognizance of complaints filed by Jain, the directorate of health also constituted a committee of three officers. Based on factual position in the case, the committee opined that;

"There was double billing and the patient paid cost for number of times for the services not provided but billed. There was lack of proper, adequate and timely co-operation by hospital authority in providing case summary to patient / attendant for second opinion, there was lack of transparency in Attendance records. Whereas, in the instant case, it is reflected that there is inadequacy of the hospital management in keeping proper checks and balances. There was absence of inherent preventive measures in the system on the above-mentioned accounts which was unbecoming of being a responsive hospital administration and management. The Committee finally, under the signature of DGHS, directed in the notice to the hospital to take corrective actions within one calendar month from the date of receipt of the notice, failing which, action may be initiated against the Hospital as per Delhi Nursing Home Registration Act and Rules."

On careful analysis of the facts and chronology of events in the instant case, the Commission observed that the two doctors and the hematologist are subject specialists with experience. It noted;

"During the hospitalization, based on symptoms and signs, the patient was investigated and treated the patient as per the standard of reasonable practice. On 20 April 2015, at the first time the diagnosis of TTP was made from the PBS and treatment with PEX was started. In my view, it was mere assumption of Jain that before 20 April 2015, the doctor failed to detect schistocytes in PBS. Mr Jain showed recovery after PEX and was discharged on 13 April 2015. As discussed above there was no delay in diagnosis and treatment of TTP."

It added;

"It is an admitted fact that, prior to starting PEX, the patient's HIV and Hepatitis-B & C viral markers were not done. It was an act of omission from OPs. However, because of such omission, the patient did not suffer any injury or loss; but in fact, the PEX Therapy was beneficial. Therefore, OPs (the hospital and the doctors) are not liable this act of omission."

Dr Kantikar went on to say;

"It is evident from the medical record that on 20 April 2015, numerous schistocytes were seen in PBS, however, the presumption of Mr Jain that such numerous schistocytes would not have developed suddenly on 20 April 2015. In my view, the doctors have ordered PBS along with a complete blood count (CBC), from 21st to 25 April 2015 and the same was billed. In the CBC report for each of those dates, the presence of schistocytes was reported. There was no evidence that schistocytes were present in the PBS before 20 April 2015, it was an imagination or presumption of Mr Jain that the doctors failed to detect the presence of schistocytes on any date prior to 20 April 2015."

""In my view, the doctor is a specialist in internal medicine, having experience and haematology is an integral part of medicine, thus he can treat the patient of idiopathic thrombocytopenic purpum (ITP). Thus, the doctor was neither prohibited to treat nor it was mandatory for him to shift the instant patient to haematology. Moreover, if necessary, there was always inter-departmental consultation or referral was possible in the Hospital. Thus, the doctor has adopted a reasonable approach for the patient's care."

The complainant had submitted that the email replies he obtained from three experts in haematology. However, the bench observed that Jain made specific queries and did not send the entire treatment record to the experts. It noted;

"The possibility of half or incomplete information was given to the experts and/or suppression of material facts cannot be ruled out. The experts have, with good intentions, replied to the emails of the complainant. In my view, such email communications are not construed as expert opinions. The experts were not called by the complainant to file affidavits or to adduce evidence. Thus, the email communications are not sufficient to hold the treating doctors for negligence or deficiency in service."

Subsequently, the bench said;

"In the instant case, I find the standard medical protocol being followed by the three doctors to the best of their skill and with competence at their command. Thus, it is clear that out of '4 Ds', the complainant has proved only the 'duty' of the Hospital and doctors but failed to prove the other ingredients of medical negligence, i.e. dereliction or breach in duty of care and the direct or proximate cause (causa causens),"

Medical negligence is discussed in catena of judgements from the Supreme Court and worldwide. In the cases of medical negligence, to bring a successful claim, the victim or victim's family bringing the action must prove the ‘four D's’ against the erring doctor or hospital. The 4 D's of medical negligence stand for 'duty', 'dereliction or deviation', 'direct (proximate) cause' and 'damages'.

In the instant case, the apex consumer body noted;

"The principle of 'res ipsa loquitur' would not be applicable, considering the medical record. "The complainant has made several allegations on the presumptions. The complaint runs in 48 pages, whereas the brief Written Submissions runs in 37 pages with 39 issues. In my view, mere averments or allegations cannot be taken as a gospel truth. The complainant has not produced cogent evidence to prove his case."

Based on the findings of the medical council of India (MCI), DHS and various medical literatures on TTP and following the precedents of the Supreme Court, NCDRC says medical negligence is not conclusively attributable to the Hospital and the doctors. The bench, however, accepted the findings of the DGHS and asked Max Super Specialty Hospital to pay Rs1 lakh to Mr Jain as compensation within four weeks.

It held;

"In conclusion, based on the findings of MCI, DHS and various medical literatures on TTP and respectfully following the precedents of Hon'ble Apex court, in my view, medical negligence is not conclusively attributable to the hospital (OP-1) and the doctors (OP-2-4)."

"However, the findings of DGHS on the administrative lapses of the hospital can't be ignored. The hospital is liable to that limited extent of administrative lapses. The hospital is strictly cautioned and directed to take necessary steps for systemic improvement. The Complainant has not produced detailed calculation of alleged excessive changes, therefore in the ends of justice, lump sum amount of Rs. 1,00,000/- (One lakh) will be just and reasonable compensation in the instant case. Accordingly, the Hospital (OP-1) is directed to pay Rs.1,00,000/- to the Complainant within 4 weeks from today, failing which the amount shall carry 9% interest per annum till its realization."

To view the original order click on the link below:

https://indiankanoon.org/doc/8502027/