Knee replacement patient dies after blood transfusion: Consumer court holds nursing home negligent over storage, orders Rs 10.25 lakh compensation
Kangra: The District Consumer Disputes Redressal Commission, Kangra, Himachal Pradesh, recently held a private medical facility guilty of medical negligence after noting irregularities in the storage of a blood unit, which allegedly resulted in the death of a patient who underwent a blood transfusion at the facility during her knee replacement surgery.
Observing that the nursing home had kept the blood unit for more than 22 hours without proper storage, the District Consumer Court President Hemanshu Mishra and members Arti Sood and Narayan Thakur have ordered it to pay Rs 10.25 lakh to the family of the deceased.
Initially, a complaint was filed by the husband of the deceased patient, and after the complainant's death, the complaint was pursued by his legal representatives.
Case Background:
The history of the case goes back to March 22, 2023, when the patient was admitted to the nursing home for a total knee replacement in the left knee. At the time of admission, the patient's vitals were stable, and the records showed no prior history of diabetes or hypertension. The surgery was performed on March 23.
Before conducting the surgery, the nursing home advised the family members to arrange one unit of blood for emergency or transfusion purposes. Accordingly, the family arranged a packed red blood cell unit from a blood centre on March 23. On the same day, it was handed over to the nursing home.
According to the records maintained by the blood centre, the blood cell unit was tested for compatibility with the patient's sample, and the report was positive. While the blood was given by the centre at 1:54 PM on March 23, the patient received the blood approximately 22 hours later on March 24.
After undergoing the blood transfusion, the patient's condition worsened, and she was referred to Dr Rajendra Prasad Government Medical College (RPGMC), Tanda, on March 25, 2023. She developed sepsis, multiple organ dysfunction syndrome, septic shock, acute kidney injury, along with suspected transfusion-related acute lung injury. Ultimately, she died on March 28.
Dr Raina, Professor of Medicine at RPGMC, Tanda, opined that the root cause of the patient's death was severe sepsis, multiple organ dysfunction syndrome, septic shock and suspected transfusion-related acute lung injury, leading to cardiopulmonary arrest.
However, in its submission before the consumer court, the nursing home denied negligence and stated that the blood transfusion was medically necessary because of the blood loss during the surgery. Further, the nursing home claimed that it had stopped when the woman developed symptoms including chills and shivering. Further, the facility cited other possible medical complications as the reasons for the patient's worsening condition.
Observation by Consumer Court:
As per the latest media report by Indian Express, the Commission observed that the blood centre had specified storing the blood at 2 degrees Celsius to 6 degrees Celsius in a dedicated blood-storage refrigerator. Further, the centre had directed that the transfusion should be completed within four hours after issue. Further, the centre also referred to the applicable transfusion guidelines that required appropriate storage and administration of the red blood cells at the proper time.
The Commission noted that the nursing home could not establish proper storage of the blood. It further took note of the fact that the temperature monitor of the refrigerator was non-functional and the temperature chart was illegible.
Apart from these, the Commission also flagged contradictions in the transfusion records. While the transfusion time was recorded in the flow sheet from 12:45 PM to 12:55 PM, it was recorded that the adverse reaction occurred between 11 AM and 1:10 PM. Further, there were differences in the respiratory rate and oxygen saturation records as well.
Further, the Commission found faults in the discharge summary for omitting the transfusion and adverse reaction. Noting the same, the Consumer Court termed the discharge summary as deficient and incomplete.
Taking all these factors into consideration, the Consumer Commission held the nursing home liable for negligence for its failure to follow standard procedures and discrepancies in its records. However, finding no negligence against the blood centre, RPGMC, Tanda or the Health Department, the Commission exonerated them.
In its order, the Commission reportedly issued directions to the treating Nursing Home to pay Rs 10 lakh compensation to the complainants and Rs 25,000 towards cost of litigation. It also directed the nursing home to deposit a punitive fine of Rs 50,000 into the District Consumer Legal Aid Fund, Kangra.
Further, the Commission held that the insurers were neither necessary nor proper parties to the consumer complaint. However, it allowed the nursing home to seek indemnification under the applicable insurance policy and directed the concerned insurer to process and settle the claim within 30 days.
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