Ignoring High Creatinine Levels, not referring to Nephrologist: Neurologist told to pay Rs 20 lakh
New Delhi: Holding a neurologist guilty for missing out on the high creatinine level of patient, not giving treatment or advising patient to visit a nephrologist, the National Consumer Disputes Redressal (NCDRC) commission recently directed a Lucknow neurologist to pay Rs 20 lakh compensation. The court held negligence on the part of the nephrologist for prescribing iron injection, contraindicated to CKD patients without testing TSAT and ferritin levels,
The case dates back to 2011 when the patient visited a Neurologist at Sahara Hospital, Lucknow followed by subsequent visits. In 2012, the patient was admitted for a day where his pathology tests were done including serum creatinine was tested and found to be 3.43 as against the range of 0.7 – 1.2.
No further investigations or treatment for monitoring and management of the high serum creatinine which was indication of a kidney disease was advised to him at the time of his discharge from Sahara Hospital, nor was he advised to consult a Nephrologist for the said purpose
In 2013, he was once again admitted in the hospital and was seen by the Neurologist along with a Nephrologist, who informed that the patient was suffering from end-stage renal disease and required dialysis.
Thereafter, the complainant moved the forum alleging negligence in treatment by the medical practitioners. The complainant added that during the stay he was allegedly administered Encicarb, an iron injection without checking the complainant's ferritin level. Moreover, during the course of his further treatment after discharge in 2014, He was further prescribed iron injection on 18.3.2014 and 26.6.2014 namely Encicarb, without checking his ferritin level.
The complainant added that he was also advised to take Metformin and Liofen. As per the complainant, this is contra indicated in the case of a person suffering from kidney disease.
Alleging negligence on part of the doctors and the hospital , the complainant approached NCDRC, seeking compensation for the damages to the extent of Rs.24,81,28,253/-, along with compensation for mental agony etc., quantified at Rs.4,80,00,000/-. He also sought a sum of Rs.3.8 crores for his future medical expenses.
Responding to this, the respondent's counsel denied all allegations of negligence. It was stated in the written version filed by the opposite parties that the complainant was a chronic alcoholic with a long standing history of Diabetes Mellitus. He was also found to have kidney disease with Urosepsis and chronic liver disease. It is also stated that 40% of the patient with type-I or type –II diabetes mellitus develops nephropathy, which is a common cause of chronic renal failure.
It was stated in a written version that in 2012 when the patient was discharged ,it was thought that the impairment of his kidney function could be due to dehydration and should be managed conservatively.
In 2013, the complete iron profile of the complainant was done and he was treated with injection ‘Cresp’ and oral iron but he continued to remain anaemic, despite aggressive erythropoietin and oral iron. No intravenous iron was given to him during hospitalization. Moreover, the complainant was advised to take injection Encicarb to be infused in two hours daily for two days after a detailed discussion on the pros and cons of the therapy. In clarification regarding the ferritin level, it was stated;
"Since erythropoietin is a costly therapy, India Society of Nephrology suggests a trial of IV Iron in anaemic chronic kidney disease if TSAT (transferrin saturation) is less than 30% and Ferritin is less than 500. The saturation of the complainant at that time was 11.42% and his serum ferritin was 258.1 on 10.12.2013. It is also claimed that it was not necessary to check ferritin before prescribing each dose of IV iron."
After hearing both the parties, Justice V K Jain made observations on all the allegations including no consultation to nephrologist in 2013 and giving medicines contra-indicated to CKD patients. On ignoring the creatinine levels, the court held the Neurologist guilty
A perusal of the discharge summary would show that high serum creatinine was not even noted in the said discharge summary. Despite the serum creatinine level being so high, neither any monitoring or management by way of periodical investigation was advised to him, nor was he asked to consult a nephrologist.The case of the opposite parties is that they thought that the serum creatinine level might have increased due to dehydration. The discharge summary however, does not record any such assumption. Even if the opposite party / treating doctor was of the opinion that high creatinine level could be due to dehydration, the least expected from him was to note it down in the discharge summary and advise the patient to get his creatinine level checked regularly, since the said level would have come down in due course had the same been caused by dehydration.
In fact, considering the high level of serum creatinine, the opposite party No.2 Dr. Sandeep Agarwal ought to have suggested consultation by a Nephrologist to confirm the cause of the increase in serum creatinine. Therefore, it would be difficult to say that the opposite party No.2 Dr. Sandeep Agarwal was negligent in the treatment of the complainant, he having not given any treatment or advise to him for the monitoring, management and treatment of the high level of serum creatinine found nor having advised him to consult a Nephrologist during the course of his treatment and at the time of his discharge on 25.9.2012. As a result of this negligence, the complainant could not get any treatment for his kidney disease for more than one year.
The forum also observed that admittedly by the nephrologist, Encicarb injection was advised to the complainant, however, the TSAT and ferritin levels were not checked before advising the drug to the patient. When the Endoscopy of the complainant was done at Fortis Memorial hospital within about two months of his taking injection Encicarb, his system was found overloaded with iron.
Similarly, the court held the neurologist negligent in prescribing Liofen to the CKD patient
The forum also noted that the complainant's plea was rejected by the Ethical Committee of Uttar Pradesh Medical Council. However, the commission noted that the recommendation by the Ethical Committee does not contain any justification for the Neurologist not advising any monitoring and management of the high creatinine, at the time of discharge of the complainant. The recommendation also does not deal with prescribing the medicine Liofen to the complainant, despite his suffering from chronic kidney disease at the time the said medicine was advised, the NCDRC noted. Therefore, the complaint cannot be rejected in view of the aforesaid recommendation of the Ethical Committee of Uttar Pradesh Medical Council, the forum held.
The court noted;
I hold that the opposite party No.2 (neurologist) and opposite party No.3 (nephrologist) were negligent in the treatment of the complainant, who died during pendency of this complaint. Since they were working with Sahara Hospital Lucknow, the said opposite party is also vicariously liable for the aforesaid negligent acts of opposite parties No. 2 and 3.
Considering all the facts and circumstances of the case, the medical practitioners and the hospital were directed to pay a sum of Rs 30 lakh as compensation to the complainant . Out of this the court directed the neurologist to pay Rs 20 lakh while the nephrologist will pay sum of Rs 10 lakh. Since hospital was vicariously liable, the court directed that the complainant shall be entitled to recover the whole of the said amount from opposite party No.1. The opposite parties shall also pay a sum of Rs.25,000/- as the cost of litigation to the complainants, the court held.
