Bhopal: Holding negligence on the part of doctors and overturning the decision of the National Consumer Disputes Redressal Commission, the Supreme court recently directed a hospital to pay a compensation of Rs 15 lakh in the case of a dengue death.
The case concerned 56-year-old Madhu Manglik who was admitted to the Chirayu Health & Medicare hospital at Bhopal in 2009. She was diagnosed with dengue fever with symptoms of dengue fever including headache, body ache and a general sense of restlessness. The patient had a prior medical history which included catheter ablation and paroxysmal supra ventricular tachycardia suggestive of cardiac complications.Since the patient was complaining of abdominal discomfort, ultrasonography of the abdomen was carried out.
Later on the date of admission, the patient began sinking, her blood pressure was non-recordable, extremities were cold and the pulse was non-palpable. In the meantime, the patient was placed on a regime of administering intravenous fluids. The administration of 2500ml of fluids was planned over the course of 24 hours. Between 7 am and 6 pm, she was administered about 1200 ml of fluids. The patient developed bradycardia and cardiac arrest. Faced with this situation, the treating doctors administered about 1.5 litres of extra fluids. Fluids and colloids were administered for increasing the blood pressure.
Since the blood pressure of the patient did not improve, she was administered ionotropes (dopamine & non adrenaline). At 6.45 pm, the patient suffered a cardiac arrest. Her cardiac levels were monitored. At 6.55 pm she was examined by Dr C C Chaubey. 8 Belatedly, at 7.15 pm, another blood sample was taken, which indicated that the platelet count moved down to 19000. At 8 pm, the patient had a cardiac arrest. She was declared dead at 8.50 pm.
Alleging negligence on the part of the doctors, the husband of the patient went to the Medical Council of India to register a complaint.
The Ethics Committee of the Medical Council of India concluded that the treatment provided by the doctors to the patient was in accordance with the established medical guidelines but not timely. The committee issued a warning to the doctor and be careful in the future. The Ethics Committee observed:
“…..After perusing the statements given by both the parties and documents on record in the case, the Ethics Committee discussed the matter in detailed and noted that the patient admitted in Chirayu Health & Medicare Pvt. Ltd., Malipura, Bhopal on the advice of Dr. A. Goenka but he never visited in hospital to see the patient. The committee further noted that treatment administered to the deceased in the hospital was correct as per the medical guidelines but not given timely. Although, Dr. Goenka did not went (sic)to hospital to see the patient as the patient admitted there as per his assurance and advice, therefore, the Ethics committee prima facie found that there is a professional misconduct on the part of both the doctors and decided to issue a warning to Dr. A. Goenka and Dr. Abhay Tyagi with the directions to be more careful in future while treating such type of patients/cases”
The complainant moved to the State commission seeking an award of compensation in the amount of Rs. 48 lakhs on the ground that the patient suffered an untimely death due to the medical negligence of the treating doctors at the hospital. The SCDRC directed the hospital to pay compensation of Rs. 6 lakh to the family of the patient.
The complainant then moved to the NCDRC and the claim was dismissed by the commission.
Assailing the decision of the NCDRC the complainant approached the Supreme Court, learned counsel appearing on behalf of the appellant submits that:
(i) The patient was admitted to the hospital on 15 November 2009 with a reported case of dengue, though in a stable condition;
(ii) The hospital and the treating doctors failed to follow the established protocol in treating a case of dengue;
(iii) The line of treatment was contrary to established guidelines, formulated by the World Health Organisation, titled “Dengue Guidelines for Diagnosis, Treatment, Prevention, and Control”;
(iv) Except for the blood sample which was taken at about 7.30 am, no further effort was made to determine the hematocrit levels (HCT) during the course of the day and it was only when the patient suffered a cardiac arrest after 6 pm that blood investigations were done at about 7.15 pm;
(v) The trajectory of the illness indicated that the platelet levels which stood at 1,79,000 on 14 November 2009 had recorded a steep decline and stood at 97,000 on 15 January 2009 when she was admitted to the hospital;
(vi) Admittedly, fluids were administered to the patient as a part of the treatment protocol;
(vii) The administration of fluids ought to have been accompanied by regular monitoring of blood levels which would have indicated that there was a precipitous decline in the platelet counts and in the HCT levels;
(viii) Plasma leakage, hemorrhagic fever or dengue shock syndrome are likely concomitants in the trajectory of such a disease;
(ix) In the absence of regular monitoring, the treating doctors were guilty of medical negligence. As a result of their negligence, the doctors precluded themselves from receiving information in regard to the status or progression of the disease;
(x) The findings of the SCDRC were reversed by the NCDRC without any basis or justification;
(xi) NCDRC has found fault with the patient’s family for the administration of aspirin in the day preceding her admission to the hospital;
(xii) The fact that she was administered aspirin was disclosed to the treating doctors at the time of admission, which is satisfactorily established by the medical records of the case; (xiii) NCDRC, in the first appeal, has displaced the findings of fact which have been arrived at by the SCDRC without any basis in the evidence on record; and
(xiv) On the question of compensation, the appellant had also instituted a first appeal before the NCDRC since the award of compensation was inadequate. On the material which was placed on the record before the original authority, it is necessary for this Court to allow the appeal and to suitably enhance the amount of compensation.
On the other hand the counsel on behalf of the hospital submitted that,
(i) The patient had been suffering from fever from several days prior to her admission to the hospital. She was stable at the time of admission on 15 November 2009;
(ii) The patient did not go into a situation of a dengue shock syndrome or hemorrhagic fever during the course of the day when she was admitted to the hospital;
(iii) In such a situation, no requirement of regular monitoring of HCT was warranted in accordance with the guidelines which have been prescribed by the Directorate of National Vector Borne Diseases Control Programme (DNVBDCP);
(iv) The above guidelines, which have been prescribed by the Union of India under the National Rural Health Mission, would indicate that it is only in a situation involving dengue hemorrhagic fever or dengue shock syndrome that further steps would be necessary;
(v) The fluids which were administered to the patient did not require a monitoring of the blood more than twice a day and it was only in the evening that the HCT levels were required to be evaluated;
(vi) The patient had prior cardiac complications for which she had been on an aspirin regime prior to admission to the hospital. She was carefully monitored by a team of four doctors at the hospital;
(vii) The treatment protocol which was followed was consistent with the guidelines which have been prescribed both by WHO as well as by the National Vector Borne Diseases Control Programme;
(viii) As held in the decision of this Court in Kusum Sharma v Batra Hospital and Medical Research Centre3 , the duty of care which is required of a doctor is one involving a reasonable degree of skill and knowledge; and
(ix) The patient in the present case had prior complications and the treatment which was administered followed an established protocol.
The Supreme Court went through the case thoroughly on the basis of the record and in the counter affidavit which has been filed by the respondents. The Supreme Court also through the medical literature including WHO guidelines laid down on Dengue
The court iterated the history and literature of medical negligence jurisprudence in India. The court went through several Jacob Mathews and Balom test.
“Our law must take into account advances in medical science and ensure that a patient-centric approach is adopted. The standard of care as enunciated in the Bolam case must evolve in consonance with its subsequent interpretation by English and Indian Courts. Significantly, the standard adopted by the three-judge bench of this Court in Jacob Matthew includes the requirement that the course adopted by the medical professional be consistent with “general and approved practice” and we are bound by this decision.”
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.
Going through the case in detail, the court held medical negligence
In the present case, the record which stares in the face of the adjudicating authority establishes that between 7.30 am and 7 pm, the critical parameters of the patient were not evaluated. The simple expedient of monitoring blood parameters was not undergone. This was in contravention of WHO guidelines as well as the guidelines prescribed by the Directorate of National Vector Borne Diseases Control Programme. It was the finding of the Medical Council of India that while treatment was administered to the patient according to these guidelines, the patient did not receive timely treatment. It had accordingly administered a warning to the respondents to be more careful in the future. In failing to provide medical treatment in accordance with medical guidelines, the respondents failed to satisfy the standard of reasonable care as laid down in the Bolam case and adopted by Indian Courts.
The court also held that the NCDRC had before it a well-considered judgment of the SCDRC based on the evidence on the record.
While the jurisdiction of an adjudicatory authority in a first appeal is co-extensive with that of the original authority, the NCDRC has displaced the findings of fact which have been arrived at by the SCDRC without any cogent reasoning.
The appellate authority has placed a considerable degree of reliance on the fact that the patient was on aspirin. This circumstance was drawn to the attention of the treating doctors at the time of admission. The NCDRC has merely observed that once she was admitted to the hospital, the patient was given medicines. This, in our view, is an insufficient basis to displace the findings of fact and conclusions recorded by the SCDRC.
For the above reasons, the court held that the judgment of the NCDRC is unsustainable. There was no basis or justification to reverse the finding of medical negligence which was arrived at by the SCDRC.
The court, therefore, directed the compensation of Rs 15 lakh to be paid to the complainant. The court however, absolved the director of the hospital holding that he wasn’t a part of the treatment