Negligence in Intracranial Stenting: Hospital pulled up for appointing doctor without verifying enrollment with Medical Council, Rs 16 lakh compensation ordered

Chennai: The District Consumer Disputes Redressal Commission, Kanchipuram recently directed a private hospital and its consultant doctor to pay Rs 16.36 lakh as compensation to the patient, who suffered a paralytic stroke after undergoing a Right Middle Cerebral Artery (M1 Segment) Intracranial Stenting.

It was observed by the consumer court that the consultant doctor, who conducted the procedure, did not have requisite qualifications. Further, the Commission held the treating hospital- Gleneagles Global Health City negligent for engaging the doctor without verifying his qualifications. Apart from this, deficiencies and discrepancies were noted in consent forms, progress notes etc.

The history of the case goes back to 2017 when the complainant's wife was diagnosed with symptoms of seizure and was taken to the treating hospital for review. The patient consulted the Head of the Neuro Science department and a consultant doctor.

As per the complainant, the consultant Dr Grahadurai conducted a D.S.A test (Digital Angio of Brain). After examining the report of the D.S.A test, the doctor advised a procedure for inserting a stent in one of the veins, on the right side of the brain. 

The doctor had opined that one vein on the right side of the brain was very thin with an opening of 10% only and suggested inserting a stent in the said vein to make function 100% for the flow of blood. Following this, the doctor performed a surgical procedure known as Right Middle Cerebral Artery (M1 Segment) Intracranial Stenting, under local anesthesia. 

Before the surgery, the patient could move all the limbs with a power grade of 5/5 of all limbs, used to walk without any physical support and did not have any problem in her speech, around 6 hours post-procedure, the doctor observed the sudden onset of weakness of the left side with dysarthria and left facial asymmetry. Consequently, the patient had worsening of power on the left side and was advised to undergo aggressive physiotherapy and continuous medical management.

Further, the complainant alleged, that after the surgery, when the patient was in the ICU, even under the constant observation of doctors, she suffered complications and the complainant had been informed that the patient had a paralytic stroke. The condition of the patient during discharge was power grade 5 on the right side, left 1/5 in the upper limb, and 2/5 in the lower limb.

The complainant claimed that instead of suggesting a non-surgical way of treatment, the doctor had hastily carried out a surgical procedure that had worsened the patient's condition. According to him, the doctor should not have performed the surgery with the possibility of such risk factors and also claimed that the doctor left her with an attack of paralytic strike involving non-movement of the left hand and left leg, facial asymmetry, and speech. 

Referring to the doctor's claim that all the details of the risks associated with the surgery were explained to the patient's family, the complainant claimed that if they had been explained such risks, they would not have consented to the surgical procedure and opted for alternate treatment.

The complainant submitted that even though a written consent letter was obtained from him, it was never explained to him that there would be post-operative complications including paralytic stroke and "worsening of power on the left side". Therefore, alleging that it was not an "informed consent", the complainant alleged deficiency in service by the hospital and its doctors and filed the consumer complaint seeking compensation.

On the other hand, the doctors and the hospital denied all the allegations of medical negligence. Referring to the patient's medical history and test reports, they submitted that the patient was under continuous medical management and had been encountering recurrent minor strokes on account of 90% blockage which had to be mandatorily intervened by the intracranial stenting in order to prevent the major stroke. 

Considering the worsening condition of the patient and anticipating complete blockage of the bilateral segments, the treating doctors had duly advised the patient and her attenders for the intracranial stenting which is found to be the most minimally invasive non-surgical interventional procedure for treating the patient's medical condition.

They further claimed that they had multiple counselling sessions with the patient and her family and had explicitly discussed the treatment options, along with the pros and cons of the procedure including the risks such as major stroke, complications & possibility of adverse outcomes in carrying out the same. 

After getting the signatures of the patient and her family members, the Right middle cerebral artery (MI segment Intracranial stenning was planned and carried out.

Referring to the Medical Records, the Commission observed at this outset that the procedure was conducted uneventfully as the patient was hemodynamically stable at the time of the procedure and no neurological deficits were present after completion of the process. 

However, around six hours after the process, the patient suddenly developed a stroke and the medical team performed all required tests including CT and MRI brain as per procedure. After this, the patient was put under appropriate medications upon the expert opinion given by the strike team. It was submitted by the hospital and doctor that the said strike suffered by the patient was an inherent risk associated with the procedure which was duly explained to the patient. They further pointed out that peri-procedural ischemic strokes are predominantly perforator strokes which occur mainly due to forceful displacement of atheroma into perforator ostia. After the patient became hemodynamically stable, she was shifted to the ward and was later discharged with instructions on supportive/rehabilitative therapies and medications.

The counsel for the hospital and doctors further argued that the Medical Board constituted by Rajiv Gandhi General Hospital Chennai had examined the procedure done to the patient and had held that there was no evidence of medical negligence. Similar opinions were given by the Tamil Nadu Medical Council, which had exonerated the hospital and doctor.

While considering the matter, the Commission took note of the expert opinion dated 11.09.2020 received from the Regional Medical Board of Rajiv Gandhi Government General Hospital and the order passed by the Tamil Nadu Medical Council.

Referring to the Council's order, the Commission noted that even though the Complainant had questioned the academic qualification and the competency of the treating doctor to perform the surgery, the disciplinary committee nowhere discussed the qualification and the competency of the doctors including the consultant doctor who had treated the patient.

Even though there were details regarding the qualifications of the Head of the Neuro Science Department, the details of the qualifications of the consultant doctor and other team members were missing. The HoD stated that he had neither recommended nor performed the Intracranial Stenting Procedure. So, the consultant doctor performed the Intracranial Stenting procedure for the reasons best known to him.

"...the Disciplinary Committee of Tamil Nadu Medical Council, was silent on the allegation that the said Dr.Satheesh Grahadurai has not having registration with the Tamil Nadu Medical Council to practice Neuro-surgery. Therefore, Dr.Satheesh Grahadurai, the 2nd opposite party herein is duty bound to prove that whether he is competent to perform Endovascular Neuro - surgery and why he has not registered his competent educational qualifications with the Tamil Nadu Medical Council to practice Endovascular Neuro surgery / procedures," the Commission observed at this outset.

Further referring to the fact that the doctor abstained from cross-examination to prove his competency, the Commission noted, "Thus, though this Commission has provided ample opportunities to the 2nd opposite party to prove his competency, the 2nd opposite party willfully disobeyed the order passed by this Commission and abstained to appear for cross examination for the reasons best known to him. If the 2nd opposite party has acquired the requisite qualification to perform Intracranial Stenting procedure on the patient, namely Mrs.***, the 2nd opposite party could have appeared for cross-examination."

Noting that the doctor had violated the Hippocratic Oath taken by the doctors, the Commission further observed, 

"...the 2nd opposite party has neither filed any documentary evidence to prove that he had competent skills to perform Intracranial Stenting procedure, nor appeared before this Commission for cross examination to enable the complainant to controvert the competency of the 2nd opposite party. Therefore, it is presumed that the 2nd opposite party did not possess minimum skill and competency to perform the intracranial stenting procedure. Both, the Medical Board Constituted by Rajiv Gandhi General Hospital and The Tamilnadu Medical Council had not deliberated the qualifications and competency of 2nd opposite party in their respective opinion / decisions. Therefore, there is merit in the contention of the complainant’s Counsel that the complainant’s wife, the patient suffered stroke which is a direct result of negligence and incompetency of the 2nd opposite party."

In this regard, the Commission also held the hospital liable for indulging in unfair trade practice for engaging the doctor as a consultant for Neuro Intervention and Neuro-Radiology without scrutinizing or verifying the qualification and competency of the said doctor.

Further, the consumer court referred to the argument that the patient had a history of one week of repeated attacks of left upper, lower limbs weakness and recurrent TIA based on which the Intracranial Stenting Procedure was performed. However, the Commission noted that the doctor and the hospital neither filed the OPD consultation records nor the CT or MRI reports taken before the date when the procedure was conducted.

"There is no iota of evidence to prove that the patient had recurrent TIA prior to 01.12.2017. Therefore, burden of proof lies upon the opposite parties to prove that the patient was advised to undergo the Intracranial Stenting procedure because of her of medical conditions and also the competency of the 2nd opposite party to perform the said procedure," observed the Commission, further holding that there was no merit in the contention of the doctor and hospital.

Regarding the issue of consent, the Commission referred to the consent for Anesthesia and noted that the doctor and hospital obtained a signature in a blank form without even mentioning the patient's name. 

"The alleged consent form for Anesthesia does not reveal which type of anesthesia was administered to the patient. Such act of opposite parties also amounts to deficiency in service," noted the Commission.

It also highlighted several discrepancies in the high-risk consent for the Right Middle Cerebral Artery concerning the timings in the progress notes. The Commission noted that in case of the high-risk consent also, signatures were obtained on a blank ruled paper.

"When the opposite party obtained other consent in a printed form, it is the opposite parties who should explain why the high risk consent was obtained in progress note sheets...Therefore, Ex.B4 cannot be treated as a consent in the eye of settle proposition," it observed.

Referring to the Progress Notes and repugnancies in recording the timing of each procedure, the Commission opined that the doctor and the hospital manipulated the medical records by interpolating certain procedures to cover up their misdeeds.

Relying on the Supreme Court orders in the case of Dr Laxman Balkrishna Joshi v Dr Trimbak Bapu Godbole, Jacob Mathew v State of Punjab and other relevant judgments, the consumer court observed, "In the practice of medicine, there could be varying approaches to treatment. There can be a genuine difference of opinion. However, while adopting a course of treatment, the medical professional must ensure that it is not unreasonable. The threshold to prove unreasonableness is set with due regard to the risks associated with medical treatment and the conditions under which medical professionals function. This is to avoid a situation where doctors resort to ‘defensive medicine’ to avoid claims of negligence, often to the detriment of the patient. Hence, in a specific case where unreasonableness in professional conduct has been proven with regard to the circumstances of that case, a professional cannot escape liability for medical evidence merely by relying on a body of professional opinion."

Therefore, holding the hospital and doctor guilty of medical negligence, the Commission directed them to pay Rs 16,36,176 towards compensation for mental agony, deficiency in service and unfair trade practice including a sum of Rs 6,36,176 spent by the complainant towards the treatment charges. Apart from this, they were directed to pay Rs 25,000 as cost of the proceedings to the complainants.

To view the order, click on the link below:

https://medicaldialogues.in/pdf_upload/gleneagles-global-health-city-compensation-243549.pdf

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