Every inpatient fall cannot be considered result of malpractice unless caused by medical negligence: Commission absolves Indraprastha Apollo Hospital

Justice Sangita Dhingra Sehgal (President), Pinki (Judicial Member) and J. P Agrawal, (Member Judicial) clarified that to constitute a fall injury in a medical facility, the fall must have been the result of a medical provider’s failure in providing an acceptable level of care.

In the instant case, medical record suggested that the patient was immediately attended to after the fall and all necessary actions were taken but if the patient did not survive, the blame cannot be passed on to the Hospital and the medical staff/doctors who provided all possible treatment within their means and capacity, the Court further said.

The Case

The case concerns a gastroenterology patient diagnosed and treated for obstructive jaundice and intra hepatic cholangiocarcinoma at the Pushpawati Singhania Research Institute for Liver, Renal and Digestive Diseases and at Medanta Medicity, Gurgaon in 2013. In 2014, the patient was first admitted with the Indraprastha Apollo Hospital in the Department of Medical Oncology for chemotherapy. The patient was thereafter admitted with the facility on four occasions and was discharged on the same dates after chemotherapy.

The patient was admitted in the Department Gastroenterology for further treatment, where he was noted to have altered sensorium, not responding to commands and sustained a fall. It was alleged that when the patient had to answer the urge of urination, and rang the bedside bell, there was no duty nurse available in the room. The attendant, brother-in-law of the patient, had immediately tried to arrange the pot for urination, which was kept under the bed, however, in a split of second, the said patient fell from the bed. The attendant helped the patient to get onto the bed, and a little while after that the patient lost his senses and never recovered.

Thereafter, the patient was shifted to Liver ICU at and put on ventilator support. The kin of the patient submitted in their complaint that they were in a total state of shock and requested to refer the patient to some other hospital, if Apollo was unable to handle the patient. The doctors of the facility allegedly retorted to invoke the "LAMA", without any referral notes for another institute. They claimed to have no choice but to continue the treatment with Indraprastha Apollo. Eventually, the patient expired and the death certificate reflected cause of death as intracranial bleeding along with Metastate Cholangiocarcinoma.

Aggrieved, the deceased patient's wife, two daughters and mother filed a complaint with the Commission alleging medical negligence and seeking a compensation of over Rs 70 lakh.

The Allegation

The Complainants submitted that the head injury was thoroughly documented by the Hospital but there was not even a single clinical observation or investigation directing towards bleeding by pre-exisiting ailments. Secondly, it submitted that neither the patient nor the attendants were educated about the alleged risks of fall. Thirdly, it submitted that the treating doctors of the Hospital insisted the Complainant to sign a printed document “Apollo Fall Risk Assessment Tool (ARFAT)” and had forged and inserted instructions related to “Education on Fall Prevention” above the signatures of the deceased's wife.

It further submitted that the deceased was oriented and in his senses, still his signatures were not obtained on the alleged document and the facility filled the columns on its own accord. The Complainants submitted that the sheer disregard of standard medical practice and lack of competence of the Hospital made the death inevitable, and as such necessity arose to file the present Complaint.

Response to the Allegations

In reply to the allegations, the hospital submitted that the attendant of the patient took it upon himself to make the patient sit without awaiting for help from the staff and thus left the patient vulnerable to a fall. Secondly, it submitted that the patient/deceased was a case of advanced metastatic cancerous disease, had severe jaundice with deranged liver functions and deranged coagulation parameters (prolonged Prothrombitine) which made the him very prone to bleeding anywhere in the body including intra-cranial bleeding.

Lastly, it submitted that the Nursing Admission Assessment & Action record clearly shows that the vitals of the patient were taken by the nurse on duty and the patient as well as his attendant were explained the use of side rails, call bell, visitation policy, rules regarding safety precautions at the time of allotment of the bed.

Observations

After hearing the counsel for the parties, the Commission, noted that the Patient and Family Education Documentation clearly reflects that the wife of the patient was educated on “Fall Prevention Modules”. The said document bears the signature of her undertaking that she has understood the education provided. The said document also bears the signatures of the treating doctor, nurse and dietician. "Therefore, it is established beyond doubt that the Complainant was educated about the fall prevention on the very same day the patient was admitted with the Hospital," it concluded while deliberating the concern of whether the Hospital educated the patient/attendant regarding fall prevention.

The Commission further clarified on the allegation that the document Apollo Falls Risk Assessment Tool (AFRAT) was concocted by the Hospital. It said;

"The Complainants have merely made bald averments devoid of any cogent proof to show that the said document is a concocted one. It is pertinent to mention here that it is a common practice amongst medical professionals to write prescriptions/directions on documents pertaining to medical records of the patients with a view to facilitate compliance with the said prescriptions/directions. Even if it is assumed that the said instructions were inserted later, the wife of the patient was already educated on Fall Prevention Modules by the Patient and Family Education Documentation. Furthermore, It is to be noted that the bed of the patient was equipped with bed rails and a call bell. The said documents is a tool to assess the risk of fall and merely reiterating the instructions for use of already existing bed rails, call bell, fall prevention etc does not amount to fabrication."

It went on to clarify that the contention of the Complainants that no neurological consultation was taken was not sustainable as well as, the neurological status chart reflects that the patient’s total coma score based on his response to external stimuli was assessed by the Hospital.

It observed;

"The medical record suggests that the patient was immediately attended to after the fall and all necessary actions were taken but if the patient did not survive, the blame cannot be passed on to the Hospital and the medical staff/doctors who provided all possible treatment within their means and capacity."

Elaborating on the most important query of whether the Hospital’s conduct can be attributed to the fall of the patient and whether such conduct amounts to medical negligence, the Commission noted;

"Prevention of patient falls is critical; however, some hospitalized patients fall despite intensive efforts. Inpatient falls and fall related injuries continue to be a complex challenge that health care organizations face. However, every fall cannot be considered a result of malpractice unless it was caused by medical negligence. To constitute a fall injury in a medical facility, the fall must have been the result of a medical provider’s failure in providing an acceptable level of care. For instance, a doctor failed to diagnose or misdiagnosed a condition that affects the patient’s balance or the patient was overmedicated, not made aware of a medication’s side effects, or prescribed a medication that conflicted with another medication and/or the patient’s fall risk was not assessed or managed correctly."

Referring to Hon’ble Apex Court judgment titled as Jacob Mathew v. State of Punjab and Anr (2005) 6 SCC 1, among other similar judgements, the Commission concluded that;

"It is clear from the record that the bed of the patient was equipped with bed side rails and a call bell. The vitals of the patient were being timely recorded and there was never a stage when the patient was left unattended. The patient was kept under the supervision of specialist doctors. The Complainants have alleged that the nurse on duty did not respond to the call bell and the patient fell himself while making an effort to sit. Here, it is to be noted that the Complainant has herself admitted that the patient fell himself."

It further highlighted that, "the patient was admitted in the general ward where a limited number of nurses have to look after several patients, to the extent that at times a single nurse is duty bound to attend 3-4 patients. The medical staff/nurse cannot be expected to be present round the clock around the patient and can only be expected to provide reasonable care and attention to the patient."

Further, "The family attendant i.e. brother in law of the patient was present in the ward to look after the patient. It is to be noted that despite the presence of the family attendant, the patient sustained a fall. It is admitted that the patient sustained a fall within a split of a second and the family attendant despite being there in the close vicinity of the patient, could not prevent the fall. Therefore in facts and circumstances of the present case, the blame cannot be entirely shifted on the Hospital and the medical staff/doctors.," the Commission added.

Subsequently, the Commission dismissed the complaint and noted;

"In the instant case, it may be mentioned here that the Complainants have led no evidence of experts to prove the alleged medical negligence except their own affidavits. The experts could have proved if any of the doctors in the hospital providing treatment to the patient were deficient or negligent in service. A perusal of the medical record produced does not show any omission in the manner of treatment."

"As discussed above, the sole basis of finding the Hospital negligent is by way of res ipsa loquitor which would not be applicable herein keeping in view the treatment record produced by the Hospital. For the application of the maxim res ipsa loquitur no less important a requirement is that the res must not only bespeak negligence, but pin it on the Opposite Party. The experts of different specialities and super specialities of medicine were available to treat and guide the course of treatment of the patient. The doctors are expected to take reasonable care but none of the professionals can assure that the patient would overcome the ailments in all probability."

It opined that the Hospital provided standard level of fall prevention services and medical care. The hospital and the doctor/nurses exercised sufficient care in treating the patient in all circumstances. However, in an unfortunate case, death may occur. The Commission before dismissing the complaint found it necessary to remark that;

"Sufficient material or medical evidence should be made available before an adjudicating authority to arrive at the conclusion that death is due to medical negligence. Every death of a patient cannot on the face of it be considered to be medical negligence."

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