Hyderabad hospital neurologist slapped Rs 1 crore compensation for negligence in treating brain stroke patient
compensation
Hyderabad: Holding a Nallagandla-based private hospital and its consultant neurologist guilty of medical negligence resulting in the death of a brain-stroke patient, the District Consumer Disputes Redressal Commission (DCDRC), Hyderabad, directed them to jointly pay Rs 1 crore in compensation to his parents.
Apart from the compensation amount, the bench of President B Uma Venkata Subba Lakshmi and members C Lakshmi Prasanna and B Raji Reddy also directed the hospital and the doctor to pay the patient's family Rs 50,000 in legal costs.
Case Background:
The history of the case goes back to 17 August 2020, when, in the midst of the COVID-19 pandemic, the patient suffered a massive brain stroke and was found unconscious in his hostel room.
Immediately, he was taken to the University Health Centre and consequently was referred to the treating hospital. As per the latest media report by The South First, an MRI was performed on the same day, and the report revealed a "massive hyperacute infarct in the right MCA territory with complete occlusion" on the right middle cerebral artery and its branches.
The patient's attendants alleged that the patient was placed in an isolation ward without being told his treatment plan or prognosis. It was alleged that despite the requests of the patient's friends to begin treatment immediately and their assurance to arrange hospital expenses, the hospital delayed the treatment, including mechanical thrombectomy, while waiting for consent and later while waiting for the RT-PCR result. After a COVID-positive result came back, the hospital transferred the patient to a COVID-designated hospital. Four days later, the patient passed away.
His friend claimed that there was no delay in getting the patient first to the University Health Centre and later to the treating hospital, on the Centre's referral. “He was moved to *** (second) Hospital on Wednesday, August 19, and put on a ventilator, with doctors saying he had little to hope of improvement. Here, a COVID-19 test there came back negative. He was then declared brain dead," the deceased's friend told Siasat
He further added that "However, we got another test done as well, which also returned negative." The patient suffered a cardiac arrest and died on August 21, 2020.
After the patient's death, his parents filed a consumer complaint seeking more than Rs 5.6 crore compensation for loss of dependency, future income, filial consortium, mental agony, and litigation costs. The patient's university friends pursued the case under a General Power of Attorney. The proceedings stretched across six years, and the Commission took note of multiple applications, medical records, hospital case sheets, affidavits, and expert evidence.
Hospital and Doctor's Defence:
The hospital and the doctor said that by the time the patient had been brought to the hospital, the therapeutic window for thrombolysis had already passed. They further stated that "the patient was brought beyond therapeutic window period, making thrombolysis contraindicated" and the mechanical thrombectomy "could not be performed due to lack of timely consent and unclear onset time".
Further, they claimed that all the protocols were followed as per standard medical practice. They also submitted before the consumer court that after reviewing the MRI of the patient, the treating neurophysician and interventional neurologist had suggested mechanical thrombectomy on the same day i.e., August 17 itself. However, they alleged that the patient's attendants/friends of the patient wished to discuss with the patient's family to obtain consent.
According to the hospital, the friends who were accompanying the patient were not authorised to take the decision and therefore the patient was provided with conservative treatment while the neurological condition of the patient was monitored. In support of their defence, the hospital and the doctor also introduced an expert opinion from a doctor.
Observations by Commission:
The Commission examined the medical records and arguments from both sides. While deciding whether there the patient's condition deteriorated due to the delay in mechanical thrombectomy, the Commission observed that the discharge summary issued by the hospital stated that "the need for mechanical thrombolysis [was] explained to the attendants who were only friends and could not take decision."
Further, the Commission noted that the hospital itself maintained that mechanical thrombectomy could be performed within 6 to 24 hours of the onset of stroke symptoms.
At the outset, the Commission questioned the hospital on why the treating doctors, including the Neurologist, delayed the procedure by waiting for consent from the patient's family, who were physically absent and unreachable, especially when the time-window-dependent intervention (like thrombectomy) is urgent to prevent permanent, severe neurological deficits.
Taking note of the hospital's later contention that the patient was not clinically suitable for mechanical thrombectomy, the Commission observed that this was not reflected in the doctor's notes or case sheets.
"The statement that the patient’s condition was not clinically suitable for Mechanical Thrombectomy...is neither mentioned in the Doctors notes/Case sheets… nor in the written version." observed the Commission.
Referring to the 6-24 hour window, the Commission noted, "Even assuming for a minute that the attendants/friends of the patient could not tell the exact time of onset of symptoms", the 6-24 hours window was available for Thrombectomy. Accordingly, the Commission concluded that the medical team had failed to conduct the Thrombectomy within 24 hours of the patient's admission.
Observing that emergency circumstances were important, the Commission further noted that under the emergency exception doctrine, when a patient is incapacitated, immediate intervention is necessary and if the family or authorised surrogate is unavailable, the doctors can proceed without waiting for the explicit consent.
"Informed consent is an imperative rule," observed the Commission, further noting that "it is also true that there are some exceptions to the rule", including emergency situations where a patient is unconscious or incapacitated and immediate intervention is required.
The Commission further held that the doctors "ought to have proceeded with the treatment under implied/presumed emergency consent, to prevent catastrophic neurological impairment and irreversible harm to the patient."
Accordingly, the Commission held the treating hospital and neurologist "negligent and deficient in providing necessary treatment to the patient/son of the complainants."
It further observed that the doctors had a "professional obligation to render immediate emergency care without letting procedural, administrative, or consent-related hurdles delay life-saving treatment."
COVID Protocols vs Emergency Situation:
Another issue that the hospital addressed was the patient's transfer to the second hospital. Even though the patient's Rapid Antigen Test was negative on August 17, and his HCRT chest screening was reported as normal, his subsequent RT-PCR test returned positive on August 19.
The hospital defended its decision to shift the patient to a COVID-designated hospital, citing COVID protocols that applied at that time. It submitted that the hospital was a non-COVID hospital and that, under the operative government instructions, COVID-positive patients had to be referred to designated facilities.
It was argued by the hospital that the patient was not abandoned but was continuously monitored and treated and after the COVID-positive result, arrangements were made to transfer him with medical support.
However, the Commission held that the COVID protocol could not justify the delay in necessary emergency stroke treatment. It observed that the official advisories issued by the Union Ministry of Health and ICMR required the hospitals to provide emergency care without waiting for a COVID test result.
Accordingly, the Commission held that "O.P.No.1 & 2 delayed the necessary treatment and discharged the patient in a haemodynamically unstable condition on 19/8/2020."
It further observed that the hospital "ought to have conducted Thrombectomy to the patient while awaiting RT-PCR report, to prevent further deterioration and to stabilize the patient before discharging the patient."
According to the Commission, the hospital's argument that the procedure could not be performed because it was not a COVID-designated facility was "not only unjustified but considered as deficiency of service and negligence."
By the time the patient's transfer arrangements were made, his condition had already worsened. It was submitted by the hospital's counsel that while the discharge formalities were underway, the patient had developed seizures and his Glasgow Coma Scale had dropped, and the medical team then intubated him and connected him to a mechanical ventilator because of the risk of aspiration and further deterioration. Thereafter, he was taken to the second hospital.
The second treating hospital's records revealed that a CT scan showed "a large subacute infarct involving the entire right MCA territory" with significant mass effect, brain herniation and brainstem compression.
According to the records, the patient was brought in a highly critical condition with dilated, non-reactive pupils and was immediately shifted to the ICU after consulting a neurosurgeon. They submitted that the patient developed cardiac arrest during the late afternoon of 21st August. CPR was initiated, spontaneous circulation returned, and he was supported with inotropes and vasopressors. Despite this, both the pupils of the patient were dilated and fixed, and there was no response to stimuli. Ultimately, he died on 21 August 2020 at 4.11 pm.
While deciding the compensation, the Commission took note of the patient's age, education and his family's circumstances. It noted that his death deprived his parents of their primary source of future financial dependency, security, and care in the evening of their lives. Further, it recognised the emotional loss of the parents, noting that "the catastrophic loss of a young child due negligence and deficiency of service… has inflicted profound emotional trauma, grief, and severe mental agony upon the parents."
Accordingly, it awarded Rs 1 crore compensation to the parents towards loss of dependency, future prospects, filial consortium and mental agony. Further, the hospital and the neurologist were directed to pay Rs 50,000 as legal cost.
The Commission ordered them to pay the amount within 45 days, adding that in case of failure to do so, the amount will carry interest at 9 percent per annum from the date of the receipt of the order until payment.
Complaint Dismissed against COVID testing lab:
As per the latest media report by The South First, initially, the case also named the second treating hospital, its doctor, and the laboratory where the RT-PCR test had been conducted.
In their complaint, the parents alleged that the lab had issued a false RT-PCR report because the subsequent testing at the second hospital was negative. However, this allegation was denied by the laboratory, which submitted that it was a NABL-accredited facility and had complied with COVID-19 testing standards.
The laboratory claimed that its role was limited to processing the samples collected and sent by the hospital. Further, it questioned the reliability of the subsequent negative test report, contending that one of the records showed an implausibly short six-minute interval between sample collection and reporting.
However, the Commission denied to accept these allegations against the laboratory, observing that "except the bald allegation that the RT-PCR Report dt.19/8/2020 given by O.P.No.3 is a false report, there is no cogent evidence substantiating the same."
Further, it noted that the laboratory had produced its quality-control report and documentation regarding concordance in the WHO external quality assessment programme, which remained “unchallenged and unrebutted by the complainant.”
The second hospital and its doctor had also denied negligence, relying on their medical records. Accordingly, the Commission dismissed the complaint against the laboratory, the second treating hospital and its doctor.
