No Medical Negligence: NCDRC exonerates Obstetrician after 21 years

New Delhi: The National Consumer Disputes Redressal Commission (NCDRC) has recently exonerated an Obstetrician and a hospital after 21 years from charges of medical negligence while conducting child delivery of a patient, who died in the process along with the baby in the womb.

Such a decision was taken by the top consumer court after it noted that the expert opinion of the AIIMS medical board had also held that the doctor had there was no evidence of wilful negligence as claimed by the autopsy surgeon, who had produced expert opinion in favour of the complainant.

"Based on the discussion above, respectfully relying upon the judgments of Hon'ble Supreme Court and considering the facts of the instant case with the clear opinion of board of experts from AIIMS, it is difficult to hold the Opposite Party No. 2 liable for medical negligence. There was no breach in duty of care from the Opposite Party No. 2 to handle emergency arisen due to fatal AFE," noted the NCDRC.

The history of the case goes back to around 21 years ago, in the year 2000, when the complainant had taken his wife for second delivery to Surlata Hospital in Mahim, Mumbai. Dr. Sharad Gogate, who run the hospital, allegedly had advised that the child in the womb was overweight and may require caesarean section and the delivery would be on 01.10.2000.

On the other hand, the doctor and the hospital denied any negligence on their part and submitted before the Commission that when the patient had been taken to the hospital, she was not in active labour and therefore, he had advised for the monitoring of the patient throughout the night and review in the morning. Accordingly, the doctor had informed the complainant that the patient could be discharged as her due date for delivery was yet to come.

However, the complainant allegedly requested the doctor for increasing the labour pain and their house in Mulund, was far off from the hospital. It was further submitted by the doctor that he had given tablet Primiprost one hourly for increasing the labour pains. Accordingly, the nursing staff had been instructed for monitoring the labour and observing the partograph for checking the condition of the baby.

As a standard dose, the patient was given six tablets from morning to afternoon. However, when the doctor examined the patient in the afternoon, she did not have any pain and therefore, Artificial Rupture of Membrane (ARM) was performed and IV glucose with Pitocin was started for increasing the labour pain.

After developing the labour pain, the patient allegedly started developing convulsions and resuscitation was initiated immediately including head low position, suction of throat & nose, 100% oxygen through bag & mask, injection Diazepam 2cc IV, injection Effcorlin 2 cc IV. Further, the patient had been provided with artificial respiration by bag and mask and also external cardiac massage.

Despite several attempts, the patient's condition did not improve, the physician and anesthetist were called and intra cardiac injection of Adrenaline, IV aminophylline and Lasix were repeated. Meanwhile, the doctor had reportedly informed the relatives of the patient about the critical condition of the patient.

It was further submitted by the doctor that the patient didn't have any previous history of fits and did not have any heart or respiratory problem. During the ANC period, she never had high blood pressure or urine albumin or swelling of the body. The onset of sudden convulsions, fall of blood pressure and breathlessness during labour pains indicated to the possibility of Amniotic fluid embolism (AFE) which was likely cause of her sudden cardio-respiratory failure. Therefore, despite several intensive efforts, the patient could not be saved.

Similar facts had been submitted by the physician Dr. Sunil Gokhale, who informed the commission that the patient had initially responded to the resuscitative measures as well. Further, the anesthetist had also submitted that he had joined the CPR team after receiving an emergency call. He had informed that despite the best efforts of the entire medical team, the patient failed to recover and expired.

After considering the matter, the State Commission had ruled in favour of the complainant and had directed the Hospital and doctor to pay Rs 20 lakh as compensation with interest @ 9% per annum from the date of filing the Complaint within 60 days.

Aggrieved, the Hospital and the doctor approached the NCDRC bench and all the parties reiterated their version of the incident. The top consumer court noted that the Complainant had presented an Expert testimony that the patient died due to Cardiac Tamponade and Pulmonary embolism. This expert opinion was given by Dr. M. D. Gupta, who had conducted the Post Mortem of the patient's dead body. On the basis of the PM findings and medical records, he opined, "Considering all these facts it appears that there was gross carelessness (willful negligence) on the part of the doctor in taking care of the patient. As far as whose life (Mother/Child could have been saved) If proper measures would have been taken atleast one of either's life could have been saved."

Finding these two opinions to be contradictory to each other, the top consumer court had sought another opinion from the expert Medical Board from AIIMS. The AIIMS board opined in its report, "The Histopathological report provided to the medical Board was examined and was found to be inconclusive as the tissues showed autolysis. However, the gross findings are compatible with Pulmonary edema. The Medical Board is of the opinion that Cardiac Tamponade stated as the cause of death by the Autopsy Surgeon was infact misinterpretation of cardiac resuscitation. The cause of death could be asphyxia due to seizures. Seizures in peripartum period can lead to sudden death and can have multiple causes such as electrolyte imbalance, Amniotic Fluid Embolism, Epilepsy, pregnancy Induced Hypertension etc. and may not be predictable. There is no evidence of willful negligence as stated by the autopsy surgeon."

The NCDRC bench noted that meanwhile, back in 2017, the Sessions Court in Mumbai had acquitted the doctor from charges of negligence under Section 304(A) of the IPC.

After perusing the entire matter, the top consumer court opined that the State Commission was wrong in its judgment and noted, "in our view, the State Commission has wrongly put entire reliance on the evidence of Dr. M. D. Gupta...the patient had no history of hypertension or any cardiac disease or uraemia which may cause cardiac tamponade. Dr. M. D. Gupta gave the cause of death as "respiratory failure due to pulmonary edema was cardiac tamponade''.

"The opinion of Dr. M. D. Gupta is not acceptable because he was not an expert in Obstetrics &/or Gynaecology to comment on AFE. It is surprising to note that he had directly concluded that it was due to gross carelessness (willful negligence) of the Opposite Party No. 2. It should be borne in mind that the duty of forensic expert is to perform post-mortem to find out / arrive to cause of death. The PM findings are helpful to the Courts/Tribunals, while deciding the cases. He has no duty to judge or make any comment on the alleged negligence. We further note that the PM reporting was not as per standards though the weight of lungs was normal but he stated that it was pulmonary edema. Secondly, without taking actual measurement of blood volume, 'approximately 150 ml' appears a vague and it cannot be taken as a gospel truth. It appears that the PM report was prepared based on the history, clinical notes. Moreover, the patient had no history of hypertension or uremia or trauma to cause cardiac tamponade," further noted NCDRC.

At this outset, the bench also referred to the medical literature on Amniotic fluid embolism and noted,

"Thus, AFE is an unfortunate condition that was not within the control of any doctor to anticipate or prevent. This condition was the root cause of the pulmonary edema that led to hypoxic encephalopathy, brain damage...In our view, any judgment as to the liability must be centered on the quality and speed of any diagnostic and therapeutic response when facing a potential AFE case. AFE is hard to diagnose with certainty."

"It is pertinent to note that the AIIMS Board report dated 02.02.2017 stated that gross findings are compatible with pulmonary edema. However, it clearly mentioned that Cardiac Tamponade stated as the cause of death by the Autopsy Surgeon was infact misinterpretation of cardiac resuscitation. The cause of death could be asphyxia due to seizures. Seizures in peripartum period can lead to sudden death and can have multiple causes such as electrolyte imbalance, Amniotic Fluid Embolism, Epilepsy, Pregnancy Induced Hypertension etc. and may not be predictable. There is no evidence of wilful negligence as stated by the autopsy surgeon. Therefore, on combined reading of all three expert opinions, in our view, it was the case of AFE and not cardiac tamponade. The HPE report provided to the Medical Board was examined and was found to be inconclusive as the tissues showed autolysis. The AIIMS report further stated that the cause of death could be asphyxia due to seizures. Seizures in peripartum period can lead to sudden death and can have multiple causes such as electrolyte imbalance, Amniotic Fluid Embolism, Epilepsy, Pregnancy Induced Hypertension etc. and may not be predictable. The report concluded that 'there is no evidence of wilful negligence as stated by the autopsy surgeon'," it added.

Referring to Supreme Court judgments in the case of Dr. Harish Kumar Khurana v. Joginder Singh and Others and Dr(Mrs) Chandarani Akhouri & Ors V Dr.M.A.Methusethupathi & Ors, the NCDRC bench finally noted,

"Based on the discussion above, respectfully relying upon the judgments of Hon'ble Supreme Court and considering the facts of the instant case with the clear opinion of board of experts from AIIMS, it is difficult to hold the Opposite Party No. 2 liable for medical negligence. There was no breach in duty of care from the Opposite Party No. 2 to handle emergency arisen due to fatal AFE."