New Delhi: Holding deficiency in providing service to a patient, who died with an alleged unexplained prognosis of the disease he was suffering from, the Delhi State Consumer Disputes Redressal Commission has directed the Indraprastha Apollo Hospital Limited in Sarita Vihar and its consultant Neurologist to pay Rs 10 lakh to the deceased patient’s family.
The case relates to a 43-year-old patient, Surender K Tyagi, who had complaints of numbness in the foot which gradually used to move upwards. NCV (Neuro Conduction Velocity) and EMG (Electro Myography Test) were performed which revealed an abnormal EMG. Study favoured “Anti Horne Cell Disease” (MND).
On the basis of clinical examination , laboratory report, neurologist Dr Arun Sharma diagnosed him as case of MND (Motor Neuron Disease), which was also confirmed by another neurologist.
On 10.09.2002, the patient approached Indraprastha Apollo Hospital. A fresh NCV/ EMG were carried out. Provisional diagnosis of Acute Motor Axonal Neuropath (AMAN), which is a variant of Guillane Barre Syndrome (GBS) was made by Neurologist Dr Rakesh Aggarwal, who declared the GBS curable.
He recommended for a treatment under the supervision of a physiotherapist. Physiotherapy was agreed to be performed at Yashoda Hospital, Ghaziabad. On 10.11.2002 patient started gasping intensely and was shifted to Apollo hospital. Thereafter, patient developed fever and was subjected to tracheostomy. On 23.11.2002 the ventilator was put off for a while. Patient was declared hemodynamically stable.
On 04.12.2002 Dr Bhanu Pant in his 2nd NCV/ EMG report held LMN syndrome involving limbs and muscles of respiration.
A few days later, Dr Pant confirmed the possibility of Anterior Horne Cell Disease. The next day, in the case summary, the hospital confirmed that the patient was suffering from MND. Patient was discharged from the hospital at 3.45 p.m. on 21.04.2004 in a ventilator equipped ambulance and shifted to Hapur. The ambulance reached Hapur at about 6.45 pm. Upon withdrawal of ventilator, patient died within 15 minutes.
Frustrated over the patient’s death, alleging negligence and deficiency in service on the part of the doctor and the hospital, the family moved the consumer forum with the following contentions:
- There was no basis for declaring the patient a “free patient”. Patient was thereafter abandoned resulting in development of various ailments.
- Diagnosis of anti horne cell disease should have been made. Dr Aggarwal declared that GBS was curable.
- Ventilator developed mechanical snags frequently.
- Patient developed diabetes and hospital stopped testing for sugar resulting in multiplicity of infection.
- Patients developed disease Hepatitis which is feasible only if infectious needle is employed.
- Apollo Pharmacy gave medicines which were “expired‟. Medical bill placed on record shows supply of expired medicines.
- Patient developed urination infection as well as Jaundice but claimed the same was due to improper insulation of the patient from other patients of the ward.
- The doctor started hinting at patient’s condition and stated that he could not improve and was likely to die due to complications arising because of various infections and not because of main disease.
In their defence, the hospital and the doctor filed separate written versions of their justifications on the case, which were noted by and large the same.
The contention of the hospital and the doctor was based on the report that gave a ray of hope for some treatment to the consultant that could be tried on the patient. They submitted that the family was informed that there was no guarantee for a cure even in case of GBS.
They added that the patient was taken away by the relatives against medical advice. Further adding that at times, the lab findings could be either misleading or non-diagnostic, the hospital and the doctor contended, “He was initially treated for GBS which is a treatable disease. Doctors constantly look for treatable conditions. They are forced to treat them just based on clinical suspicion.” There was no harm done to the patient by way of the treatment given, they claimed.
The doctor and the hospital detailed the symptoms that led to the diagnosis of GBS and not MND as under:
“a) The patient had presented to the emergency with the history of rapidly progressive paralysis for past ten days followed by difficulty in breathing for last few hours before he started gasping for air. This was preceded by some viral infection.
- b) On bedside examination his deep tendon reflexes were absent – a feature diagnostic of GBS (in MND are exaggerated)
- c) There was an Apollo report of NCV/ EMG done a month prior, supportive of GBS. A test done at a large institution such as Apollo carried more credibility than a conflicting report done at small centre in a small town.
- d) Doctors always look for treatable condition such as GBS. Labeling a patient with MND in a hurry is like issuing a death warrant in haste. Hence IV-IG was given to the patient.
- e) Before coming to Apollo patient had been to Yashoda Emergency were he was diagnosed ascending cervical myelitis, a condition of GBS rather than MND.
- f) The diagnosis of GBS in this patient was endorsed by two other senior neurologists early in the course of the disease – Professor G. K. Ahuja and Dr. Mukul Varma”.
Before proceeding further into the case, the Commission invited an expert’s opinion from Vinod Puri Director-Professor Neurology at GB Pant Hospital, New Delhi. The same is reproduced below:
“Patient had weakness of both lower limbs of 6-8 months duration. He was evaluated earlier, by Dr. Arun Sharma, and diagnosis of MND was made based on the clinical profile and Needle EMG evidence of denervation. However, detailed clinical details have not been provided in the enclosed Exhibits. Repeat electrophysiological evaluation at Apollo hospital reconfirms the evidence of denervation in both upper as well as lower limbs. Such electrophysiological features can be seen in Axonal variety of GBS. However, both of these entities have different clinical profile.”
Perusal of the expert’s opinion showed that the electrophysiological features in case of MND can also be seen in Axonal variety of GBS. They are overlapping. In other words, electrophysiological features could be the same in case of MND and Axonal variety of GBS, the commission noticed.
Noting all the records submitted and hearing all the contentions made by both the parties, the single bench of honourable judicial member, N P Kaushik observed,
“OP2 doctor was misled by the commonality of said features in MND and GBS. At the same time, expert opined that GBS and MND have different clinical profiles. It has not been made clear by the expert as to which clinical feature could distinguish between MND and GBS. Be that as it may, expert has not held the OPs as ‘negligent’.”
The concept of “informed consent” was explained in detail to both parties. Relevant excerpt of the judgment taken in concern is mentioned below.
“Fundamentally, the law requires the disclosure to the patient, information relating to the diagnosis of the disease; nature of the proposed treatment; potential risks of the treatment and the consequences of the patient refusing the suggested line of treatment. Disclosure of such information is the basic attribute of an informed consent and is considered mandatory in every field of medicine or surgical procedure. The only exception to the general rule is the emergency medical circumstances, where either the patient is not in a medical condition or mental stage to take a conscious decision in this regard.”
Considering the hospital and the doctor not guilty of ‘medical negligence’, but deficient in service, the bench concluded,
“In view of the foregoing reasons I am of the considered opinion that the OPs are not guilty of “medical negligence”. However, the patient was not made clear of the prognosis. Nothing was explained to the relatives in relation to the commonality of the features of MND and GBS. Relatives of the patient remained in dark in that they remained under an impression that the disease was fully curable and the treatment was as per standard protocol. OPs in the present case were „deficient in service‟ as the relatives of the patient were never explained the prognosis.”
Ultimately, the bench allowed Rs 10 lakh compensation to the patient’s family and directed the hospital and the doctor to pay the said amount.
“OPs are hence directed to pay an amount of Rs.10 lakhs to the complainants (jointly and severally) within a period of 30 days from today failing which the amount shall carry interest @7% per annum.”
Attached is the judgment below: