Bladder injury caused by Suprapubic catheterization done by Junior Resident: Hospital, surgeon slapped compensation

Presiding Member of the Commission, Dr Inderjit Sing was hearing two Revision Petitions (RPs) filed by Shallu, wife of the deceased, against Dayanand Medical College & Hospital and others. The petitions were lodged against the State Consumer Disputes Redressal Commission, Punjab's order dated March 3, 2016, pertaining to appeals filed against the District Consumer Disputes Redressal Forum's decision.

The petitioner, brought forth her grievances against Dayanand Medical College & Hospital (OP-1), a junior doctor, third year resident, General Surgery (OP-2), a Professor, Dept of General Surgery (OP-3), and United India Insurance Co. Ltd (OP-4), seeking redressal under the Consumer Protection Act 1986. The case revolves around the demise of Shallu's husband, Jatinder Kumar, due to alleged medical negligence during the course of treatment for Non-Hodgkin's Lymphoma (NHL).

The patient, Jatinder Kumar was admitted to Dayanand Medical College & Hospital for treatment of end-stage Non-Hodgkin's Lymphoma from May 30 to June 20, 2011. The hospital assured that chemotherapy could cure the ailment, and the treatment commenced. However, complications arose during the third chemotherapy session when attempts to change the catheter failed, necessitating a referral to the surgery unit. At the surgery unit, a junior doctor and a third-year medical student, were unable to change the catheter. It was explained to the complainant that there was a urinary infection, and the catheter needed to be directly connected to the urine bladder through minor surgery by a senior surgeon. The patient was then referred to the emergency ward, where OP-2(the junior doctor/resident, GS), was on duty.

In the emergency ward, the attending doctor opted to perform the procedure herself despite being a junior doctor. The petitioner alleged that the procedure was performed by an inexperienced medical student (a third-year pg medical student/a junior doctor), resulting in severe complications as following the surgery, the patient experienced extreme discomfort and was unable to pass urine.

Despite seeking further medical assistance, the patient's condition continued to worsen, culminating in the discovery of a significant hole in his urinary bladder. Subsequent surgeries and medical interventions were unsuccessful, and the patient passed away on October 4, 2011.

The petitioner alleged that despite these complications, the hospital did not transfer the patient to a urology specialist. Furthermore, chemotherapy, a critical aspect of cancer treatment, was interrupted due to the alleged negligence, ultimately contributing to the patient's demise. The petitioner filed a complaint with the District Consumer Disputes Redressal Forum, Ludhiana, alleging medical negligence.

The District Commission, in its order dated December 12, 2014, ruled in favor of the complainant (the petitioner), demanding compensation for alleged medical negligence. It held the medical practitioners responsible for the deficient service, a finding upheld by the Board of Doctors.

The three-member Board of Doctors (BODs), consisting of medical experts including a Senior Medical Officer (SMO), a Specialist, and a Radiologist, conducted a thorough investigation. Their unanimous opinion highlighted critical details regarding the medical treatment received by the patient. The Board emphasized that a standard surgical procedure, Suprapubic Catheterization (SPC), was performed on the patient despite being a high-risk patient with immune compromise and neuropathic bladder injury.

"After carefully going through all the relevant medical record, statements of the dealing doctors, Board of Doctors is unanimously of the opinion that patient Jatinder Kumar was diagnosed as stage IV NHL under treatment require supra public drainage for passage of Urine which was done at DMC, Ludhiana by the doctor (third Year Resident, General Surgery). Ordinarily SPC is a minor surgical procedure done in emergency, but in this case the patient was immune-compromised and was having neuropathic bladder injury at the rate of ultra-operative and post-operative complications is known to be higher and ideally in such high risk cases SPC should have been performed by senior surgeon or under his supervision with Anesthetic backup. As a complication of the above mentioned procedure, the patient had to undergo explorative Laprotomy and around 1-2 litres of pus was drained out and during the procedure following which patient remained in ICU on ventilator support for a considerable period of time, following which the definite treatment of Non-Hodgkin Lymphoma (Chemotherapy) was interrupted. So, in the opinion of the members of the board in this case, SPC and Later explorative laparotomy increased the morbidly and contributed to the mortality," the relevant portion of the BOD report read.

The procedure, which is typically minor, led to complications, requiring an explorative laparotomy due to a substantial pus buildup. Regrettably, this surgery disrupted the patient's chemotherapy schedule, further complicating his condition and ultimately contributing to his unfortunate demise.

Eventually, the District Commission directed the hospital and the doctors to pay Rs 3,00,000 to the complainant with a 9% annual interest on account of compensation. Additionally, a sum of Rs. 7,000/- as litigation expenses was to be paid by them. Moreover, the insurance company was mandated to reimburse the claim paid by the other parties involved.

Dissatisfied with this ruling, the petitioner filed an appeal with the State Commission challenging the Order of the District Commission. However, the State Commission, through its order dated March 3, 2016, allowed the appeal of the OP's (the hospital and the doctors), effectively setting aside the District Forum's order, and dismissed the appeal of the complainant/petitioner, seeking an enhancement of compensation.

The State Commission disagreed with the conclusion of the District Commission, questioning the competency of the treating doctor and challenging the connection between the surgical procedures and the patient's deteriorating health.

The State Commission underscored the importance of thoroughly evaluating all aspects of the case before attributing negligence. They emphasized the need to consider the patient's conduct and adherence to the prescribed treatment plan. The Commission disregarded the expert opinion of the BODs, deeming it inconclusive.

Aggrieved, the petitioner moved the apex consumer court contesting the State Commission's order on various grounds. The counsel for the petitioner submitted that the State Commission overlooked vital evidence, including a Board of Doctors' report, supporting allegations of medical negligence by the doctors. The report spotlighted the doctor's alleged independent surgery on a vulnerable patient, causing severe complications. The petitioner cited statements from the doctors to support these claims.

Moreover, the petitioner noted instances where the doctor performed a complex surgery independently, resulting in significant harm to the patient's urinary bladder. It was further emphasized that the State Commission's alleged failure to consider the interruption in chemotherapy due to the doctors' actions, intensifying the patient's suffering and potentially contributing to their eventual demise.

Additionally, the petitioner argued that the State Commission showed bias by focusing on the patient's failure to report after the surgery, disregarding the critical condition, lack of response from hospital authorities, and subsequent ventilator dependence due to the alleged negligence.

In the Revision Petition (RP), the counsel for both the parties presented their arguments. The petitioner's counsel argued that negligence led to interruptions in chemotherapy, impacting the patient's condition and eventually causing his death. On the other hand, the respondents' counsel emphasized the patient's medical conditions and the hospital's adherence to standard protocols, highlighting no initial allegations of negligence. Further, the insurance company contended that the petition lacked maintainability due to the absence of a direct contractual relationship. All the parties referenced legal cases to support their respective positions, emphasizing the need for substantial evidence to prove medical negligence.

NCDRC conducted a thorough examination of the State Commission's orders, District Forum records, medical board reports, case laws, and rival contentions of the parties. It found that the Medical Board of Doctors (BODs) unanimously opined that the patient's condition necessitated supra pubic drainage for urine passage, a procedure that was performed by a third-year resident doctor under general surgery. Due to complications arising from the procedure, an exploratory laparotomy was required, significantly impacting the patient's condition and interrupting the planned chemotherapy.

The Commission concluded that the BODs' expert opinion should hold significant weight. They emphasized that the BODs were appointed by the District Forum and were comprised of senior doctors and specialists from a government hospital. The court deemed their unbiased and clear opinion as a critical piece of evidence demonstrating negligence on the part of the medical practitioners. It observed;

"We have carefully gone through the above stated observations of State Commission for not relying upon the report of BODs, but do not find it justifiable. It was a well constituted Board of Doctors, consisting of experts and senior doctors of Government Hospital, who have given this unbiased clear expert opinion on the negligence on the part of respondent doctors. No doubt it is left to the courts/commission whether to accept or not any such opinion of such expert BODs, in the instant case, the BODs having been appointed as per orders of District Forum, consisting of expert/senior Doctors, given an unbiased clear opinion, we find no reason for not accepting such expert opinion as an important piece of evidence showing negligence on the part of OPs. Hence, we are of the considered view that State Commission went wrong in discarding the expert opinion of BODs and setting aside the findings of District Forum about medical negligence on the part of OP doctors. We have carefully gone through the orders of District Forum and note that District Forum had considered at length all the facts of the case and rival contentions of the parties as well as medical literature relied upon by the parties and have given a well-reasoned order. It is not correct that District Forum has given its findings simply based on expert opinion/report of BODs. It has duly considered other evidence also before it while concluding medical negligence on the part of OP doctors (OP-2 to OP-3) and OP-1 hospital was held vicariously liable for the acts of negligence on the part of OP-2 & OP-3. District Forum has also taken note of various case laws relied upon by the parties."

Referring to the judgement by Hon’ble Supreme Court in Jacob Mathew (Supra) case, the Commission further highlighted the difference between negligence in civil law and criminal law, emphasizing that the standard of negligence required for civil liability need not be as high as that required for criminal liability. In medical negligence cases, the key components to establish liability include proving a breach of duty, deviation from the standard of care, and resulting damages.

Subsequently, the court upheld the original findings of the District Forum, stressing the significance of expert medical opinion and emphasizing the need for a thorough assessment of all evidence in cases of medical negligence. It said;

"In view of the foregoing, we are of the considered opinion that State Commission went wrong in setting aside the order of the District Forum and allowing FA/155/2015 filed by OP-1 to OP-3. Hence, we allow RP/1924/2016, set aside the order of State Commission in FA/155/2015 and restore the order of District Forum dated 12.12.2014 in CC/24/2015, with modification with regard to liability of OP-4 Insurance Company as stated in para 15 above. As regards FA/349/2015 filed by complainant for enhancement of compensation, we are of the considered view that District Forum after considering the entire facts and circumstances of the case, have awarded a reasonable amount of compensation. As the FA/349/2015 filed by the complainant was dismissed on the grounds of FA/155/2015 having been dismissed, the State Commission did not consider the case of Complainant for enhancement of the compensation. We have carefully gone through the RP/1925/2016 filed by complainant for enhancement of compensation. Reasons/grounds for enhancing the compensation from the one awarded by District Forum are not found convincing/acceptable. Hence, RP/1925/2016 is dismissed and order of District Forum with respect to quantum of compensation is upheld. All payments as awarded by District Forum, to be made by OP-1 to OP-3, who are held liable jointly and severally, within 2 months of date of the order, along with simple Interest @9% p.a. as per order of District Forum till the date of actual payment. OP-1 shall be free to file its claim to OP-4 Insurance Company within one month of disbursement of amounts as per the order to the complainant/petitioner herein. Thereafter OP-4 Insurance Company shall process such claim on merits within a maximum of two months and disburse the eligible amount to OP-1."

The court also clarified the procedure for claiming compensation from the involved insurance company, ensuring that proper protocols are followed for a fair resolution. It held;

"As regards liability of OP-4 Insurance Company, District Forum has directed OP-4 to reimburse the claim so paid by OP-1 to the complainant. In this regard, we have considered the contentions of OP-4, that the Hospital holds a professional indemnity (Medical Establishments) Policy with OP-4 and according to the terms and conditions of this policy, OP-4 is obliged to indemnify the insured hospital. However, this liability is contingent upon specific stipulations, and it materializes only if the hospital is deemed liable for any single accident within the defined policy duration. The counsel asserts that it is the hospital's claim that OP-4 would scrutinize for indemnification. Hence, if OP-1 hold a valid policy and is held liable for negligence by competent Court/Commission, it is for OP-1 to formally lodge a claim with OP-4 Insurance Company by observing the due process and submitting requisite documents, whereupon it is incumbent upon OP-4 Insurance Company to consider such claim on merits in accordance with the terms and conditions of policy held by OP-1 and if found eligible, disburse the same. Hence, District Forum went wrong in directing OP-4 Insurance Company straightaway to reimburse the claim so paid by OP-1. To the extent, the order of District Forum needs modification."

To view the original order, click on the link below:

https://cms.nic.in/ncdrcusersWeb/GetJudgement.do?method=GetJudgement&caseidin=0%2F0%2FRP%2F1924%2F2016&dtofhearing=2023-10-12