No Negligence but hospital, doctor slapped compensation for non-maintenance of medical records

New Delhi: The National Consumer Disputes Redressal Commission (NCDRC) recently directed a Visakhapatnam based hospital and its doctor to pay Rs 1 lakh to a patient for non-maintenance of medical record.

Although the top consumer court held that there was no medical negligence by the doctor and the hospital while providing treatment to the patient for Ano-rectal abscess, it noted that the case sheet of the treatment procedure was not maintained.

"Medical records not only serve as necessary documents for apt management of a patient, they are also legal documents. These records contain useful evidence for diverse litigations including personal injury cases, criminal cases, workers’ compensation, disability determinations, and medical negligence claims. It should be borne in mind that “Good Record is Good Defense” Poor Record is Poor Defense” and “No record is No Defense.” Thus, accurate and complete medical documentation is vital for appropriate and efficient patient care," observed the NCDRC bench as it directed them to pay Rs 1 lakh along with Rs 25,000 as cost of litigation to the patient within six weeks.

The patient had filed a complaint before the District Consumer Court, Visakhapatnam against the treating doctor and Anupama Surgical Children's Hospital for alleged medical negligence during the treatment of rectal abscess. He alleged that he suffered septicemic shock and incurred huge expenses for treatment taken from different hospitals.

Allowing the complaint, the District Forum had directed the doctor and the hospital to pay Rs 6,29,300 as compensation. Aggrieved by this, the doctor and the hospital had approached the State Commission.

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Consequently, the State Commission had upheld the order as it held that there was "...deficiency in service and negligence on the part of OP in treating the complainant properly and also for the reason that they did not maintain any pre or post operation reports so also the surgical notes etc. which lead the complainant to take further treatment in care hospital."

Aggrieved by this, the doctor and the hospital had approached the top consumer court bench. It was argued by the counsel for the complainant that back in 2004 the complainant was operated for rectal abscess and the surgery had been performed without preoperative tests. 

After the surgery, the patient was kept in the intensive care unit and developed breathing problems and his health condition deteriorated. Thereafter, he was shifted by ambulance to Care Hospital, allegedly without any assistance and medical records. There, he was diagnosed as a case of Septicemic Shock and he was treated in the ICU for 10 days. Later, the patient allegedly had to take treatment in other hospitals as well.

The complainant's counsel submitted that the patient had been administered 17 injections of Xigirs 20 mg, for the total cost of Rs. 4,78,083. It was submitted by the complainant that he had incurred total expenditure of Rs 7,78,250 towards medicines, hospital, towards fees, transport and attendance charges.

On the other hand, the counsel for the doctor and the hospital argued that the District and State Consumer court had failed to consider the crucial issue of purchase and administration of injection Xigirs. It was submitted by their counsel that the patient had approached the hospital with agonizing pain in the Ano-rectal region and high grade fever for 4 days. 

In order to drain the pus, simple incision and drainage (I & D) under General Anesthesia had been suggested and the patient had agreed for the same. It was further submitted that minimum basic investigations had been conducted and the patient had been administered appropriate antibiotics. Even though the post-operative recovery was good, the patient had developed signs of septicemia and immediately the patient had been shifted to Care hospital for better management.

While considering the matter, the NCDRC bench noted that the main controversy was about the use of altogether 17 Xigiris injections at Care Hospital. In this regard, the top consumer court referred to the observation made by the State Commission which had noted, “Ex. A19 two invoices for supply of 17, XIGIRS-20 mg injections reveal that the cost of the said injections was Rs. 4,78,083/- the complainant produced empty vials in proof that the costly injections were administered to him in critical conditions. There is no clinching evidence from OP side that administering of such costly injections was unnecessary. Nobody would give such injections without there being any necessity and hence the version of the complainant that such injections were used to him in the care hospital and that he incurred expenditure of Rs. 4,78,083/- is believed as true.”

However, the NCDRC bench held that the State Commission had erred in relying upon two invoices and 17 empty vials of Xigris and to conclude that during treatment at Care Hospital, the patient was given 17 injections of Xigris (20 mg) (Drotrecogin Alfa).

"Surprisingly, it is pertinent to note that the medical record and Discharge summary of Care Hospital did not show any mention or advice about the administration of 17 injections of Xigris. I have gone through the Pharmacopeia price index, one vial of Xigris costs Rs. 84,700/-, thus the total cost of 17 vials would be Rs. 14,39,900/-, but nothing is on record to prove that 17 vials of Xigris were purchased at the cost of Rs.4,78,083/- .The treating doctors of Care Hospital have neither prescribed or administered 17 Xigris injections to the patient. Therefore, the Complainant won’t deserve the refund of amount allegedly paid for the injections Xigris," the top consumer court noted at this outset.

Referring to the medical records, the bench observed, "Adverting to the maintenance of patient’s medical record, admittedly OP-1 in her evidence deposed that she did not maintain case sheet. She did not enter in the ICU register about the surgery was done in emergency though the patient was in ICU for 6 hours. According to OP-1 it was not a major case, therefore she did not make entry in hospital register or ICU register."

After perusing the referral letter given by the doctor to the Care Hospital, the consumer court observed, "In my view in absence of medical record, the referral letter clearly mentioned about the mode of treatment adopted by the OP-1 for the painful Ano-rectal abscess. Such patient needs immediate relief from acute pain . I & D was performed after doing basic investigations viz. Blood Counts, Blood Sugar and ECG. It was reasonable standard of surgical practice."

Therefore, observing that there was no medical negligence in the treatment procedure, the NCDRC bench noted,

"In my view, it was neither failure of duty of care during pre-operative stage nor negligence while performing I & D. It is pertinent to note that the clinical signs and symptoms show the patient was already in sepsis. Post operatively patient was kept in ICU and administered higher antibiotic Monocef and other drugs as per standard practice. The complication of septicemia was managed by inj Steroid, Dopamine drip and Oxygen supply also. The patient for better treatment was referred to the higher centre - Care Hospital.In my view it was prompt referral and there was no delay. Referring the patient during absolute necessity is not negligence."

However, taking note of the matter concerning non-maintenance of medical records, the bench noted,

"Further, I can’t ignore the non-maintenance of vital medical record by the OPs. It was the primary duty of treating doctor to maintain proper treatment record including anesthesia, Operative notes , the medication, details of recovery from anesthesia etc. It should be borne in mind that, though I & D was a minor surgical procedure, OP-1 performed it under General Anesthesia and post operatively the patient was in ICU for 6 hours. Proper documentation will help to prove the doctor’s duty of care and to defend certain unavoidable and unforeseen complications. Therefore, the Petitioners (OP-1 & 2) are held liable for the deficiency in services."

Directing the hospital and the doctor to pay Rs 1 lakh for non-maintenance of medical records, the NCDRC bench ordered, "

Based on the discussion above, medical negligence is not attributable to the OPs, however OPs are held liable for non-maintenance of medical record. Accordingly, the Order of State Commission is modified that, the OPs shall pay jointly and severally Rs.1 lakh to the Complainant along with the Rs.25,000/- as cost of litigation within 6 weeks from today. Beyond 6 weeks, the OPs shall liable to pay 10% interest per annum till its realisation."

To read the order, click on the link below:

https://medicaldialogues.in/pdf_upload/ncdrc-non-maintenance-of-medical-records-200069.pdf

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