Medico Legal News

(CARDIOLOGIST )

Dear Doctor,
Our effort is to provide you with the latest and relevant developments in the field of medico legal services for this we are providing you some case references from the field of Cardiologist.

  
CARDIOLOGY /CARDIO-THORACIC SURGERY

1.1)  Cardio-thoracic surgery-Allegation of gauze left in body not proved- No negligence- The complainant had undergone heart surgery in the hospital and it was alleged that a surgery was left in her body. at the time of operation, on account of which she suffered great pain and had to undergo second operation at Bangalore. The complainant claimed compensation against the negligence of the Hospital and the Surgeon. It was contended by the opposite parties that the heart operation was successful but the post-operative X-ray examinations carried out showed a collection of fluid on the left side of the chest and the complainant was advised for operation to remove the fluid which the complainant refused although it was to be done free of charge. However she went to Bangalore and got herself operated upon where the surgical gauze was allegedly got removed. The State Commission while dismissing the complaint held that there is no evidence on record to prove that during the operation by opposite party No.2 surgical gauze was left in the chest which was removed at Bangalore. ...There is not the slightest evidence of any deficiency in service and consequent negligence of the opposite party No: 2, when he performed operation of the complainant.[Smt. Chanchal Ostwal v. SDM Hospital and Dr. Nimish A. Shah, decided on 28.11.92 by Raj. SCDRC (unreported).]
1.2)  Coronary by-pass surgery-Infection in wound in knee-Death due to brain-stem haemorrhage-No negligence-But relief granted in form of refund- The late Shri Anil Kumar Jain was admitted in the hospital on 25.2.1991 for coronary by-pass surgery which was performed on 4.3.1991 and patient was discharged on 14.3.1991.
On 21.3.1991 patient was reviewed in O.P.D. and it was found that the wound above knee was infected. He was advised dressing of the wound. He was again seen on 3.4.1991 and advised to continue dressing. He was admitted on 4.4.191 in a state of coma and died on 16.4.1991 in the Hospital. The complainant alleged negligence on grounds of premature discharge; post-operative wound infection; failure to advise tests for the determination and treatment of infection; failure to give proper treatment for infection resulting in thromboembolism which eventually resulted in the patient going into coma and death; and failure of the hospital to undertake pathological autopsy. According to the complainants this was avoided intentionally, contrary to the general practice throughout the world, only with a view to cover up the negligence and deficiencies in treatment. These allegations were refuted: the discharge was not premature; the post-operative recovery was smooth and uneventful; the condition of the patient did not necessitate or justify continued hospitalization; the infection in the wound above the knee was superficial and mild; there was no fever, no discharge; rather the antibiotics were withdrawn, and were not prescribed even when patient was received in OPD on 3.4.1991; the blood report of the patient showed that his TLC and DLC was normal; the patient died of brain-stem haemorrhage followed by acute renal failure and cardio-pulmonary arrest. The brain-stem hemorrhage had no relation with the coronary by-pass surgery 9r with the wound infection patient was a known case of hypertension which could lead to brain hemorrhage; .the hospital also placed on record the diagnosis and notes on the case sheet of the patient made by four different neurologists of the hospital after examination of the patient; two neurologists summoned by the relatives of the patient after examining him opined that the condition of the patient was either due to embolic phenomenon or cerebral haemorrhage; this was carefully considered by the court which held that this does not establish that the patient had any thrombo-embolic phenomenon or that the brain-stem haemorrhage was embolic in origin. On the question of

carrying out the autopsy the court cited the medical text from Gradwohl's Legal Medicine, third edition: "autopsy is a must when death of a person is sudden, unexplained, unexpected or violent". This was not a medico-legal case, and the cause of death had been determined precisely. On the allegation that the hospital failed to inform that he Y.'as suffering from brain-stem haemorrhage and there was little hope of recovery, the court observed that the complainant's own doctor had noted that poor prognosis had been explained to the relatives. At the conclusion of the hearing the hospital, purely on compassionate considerations, agreed to refund ex-gratia the amount of Rs. 20,000/- deposited at the time of his readmission on 4.4.1991. The court, however, made it clear that there had been no deficiency in diagnosis and treatment of the patient in the hospital, and therefore, the refund could not be interpreted, directly or indirectly, as admission of any lapse. The National Commission was assured that the complainants would accept the refund in the spirit and would not agitate the matter any further. [Renu lain v. Escorts Heart Hospital and Research Institute, 1992 (2) CPJ 391 (NCDRC).]

1.3)  Cardio-thoracic surgery- Treatment proper-No negligence-Excessive fee-Not a consumer dispute-In the instant case the Maharashtra State com- mission of Maharashtra 1 held the doctor guilty of gross negligence for failure to render necessary post-operative care which was undertaken by him for consideration (fee). This fee of Rs. 40,000 was paid by cheque a few days after the open-heart by-pass operation performed on the complainant at the Bombay Hospital, for rendering post-operative care and treatment for a period of three months. The fee was excessive, unreasonable and unjustifiable though conceding that the amount to be charged as fee for medical services is the choice of the medical practitioner. The State Commission further observed that the complainant badly needed post-operative care as pus was formed in his chest region for want of post-operative care, which could have caused death. The doctor examined the patient reluctantly on one of the post-operative follow-ups, and on another occasion did not grant interview to the patient. Hence it held that the doctor had charged disproportionately and there was imperfection, short-coming and inadequacy in the nature and performance of post-operative care and awarded a sum of Rs. 2 lac by way of compensation to the patient.
1. B.S. Hegde v. Dr. Sudhansu Bhattacharya, 1992 (2) CPJ 449 (Mah SCDRC).
On appeal against this order of the State Commission, the National Commission held that: There is no evidence of any deficiency in service on the part of the doctor or in rendering adequate care and treatment, because there was no cardiac or any other serious complication during the post-operative period. Pus formation in the stitches is a normal occurrence in the post-operation period of coronary by-pass surgery .It also noted the statement of other doctors who had subsequently attended on the patient that the discharge from the sternum was serous, there was no tenderness, patient was afebrile and vital parameters were within normal limits, and the treatment given was of a superficial nature, and could not in ordinary course cause death.
The National Commission also agreed in general with the observation of the State Commission that fee paid for an operation also includes post-operative care. But in the case of the operation being performed in an institution (hospital), it is the duty of the institution to render post-operative care and treatment. The private doctor, who is performing the operation for a fee in the hospital, cannot be expected to undertake and provide post-operative treatment and care to the hospital's patient. Quite often foreign doctors undertook operations in hospitals or nursing homes in India and it cannot be maintained that the post-operative care and treatment will continue to be provided by the foreign doctors who may no longer be in the country.
Regarding the charging of Rs. 40,000 for post-operative care and treatment it found it to be clearly unreasonable. But, however improper it may be, the demand and acceptance of an exorbitant fee can not be deemed to be deficiency in service and hence, it is not for the consumer forums to adjudicate on the question whether the consideration charged was reasonable. It also conceded that a doctor has the absolute right to decide which patient he would examine first and even out of turn depending upon the condition of the patient. He also has the right to examine patients in their turn and it cannot be maintained that a patient must be examined by the doctor at the appointed time irrespective of the time he may have to spend in examining the previous patient. In the light of above discussion the order passed by the State Commission was set aside and complaint was dismissed. [Dr. Sudhanshu Bhattacharya v. B.S. Hegde, 1993 (3) CPR 414 (Mah. SCDRC).

1.4 Cardio-thoracic surgery-Operation for mitral stenosis-Patient subsequently developed left hemiparesis-Died-Doctor's advice not followed-No negligence-Complaint dismissed-The complainant's wife Dr. Vijaylaxmi, a doctor, was operated upon for mitral stenosis, with Dr. K.M. Cherian as the Chief Surgeon. It was alleged that subsequently she developed paralysis of her left side of body and taken to Vijaya Hospital where C. T .Scan was done and Dr. K. Cherian of the 2nd Opposite Party Madras Medical Mission declared that it was not a surgical case, but a medical case and would be alright under neuro-physician ' scare, but no neuro-physician attended on her for a week and ultimately she passed away due to lack of proper and timely. The 1st Opposite Party contended that Dr. Vijaylaxmi was under the entire treatment of the 2nd opposite party which is an independent body consisting of its own specialists and assistants, and are paying charges to the 1st Opposite Party for providing them with consultation rooms and other facilities. The 1st Opposite Party provides nursing facilities, and laboratory services to these consultants. This was not disputed by the 2nd Opposite Party. Therefore the Commission held that there is clearly no employer-employee relationship (Master-Servant relationship, Principal-Agent relationship) and hence no question of vicarious liability of the 1 st Opposite Party for any deficiency in service in the treatment by the 2nd Opposite Party arises. As regards the main complaint that no neuro-physician attended on her from 15.7.1991 to 24.7.1991, there was no specific denial in the written version of the 2nd Opposite Party. Perusal of available records led the Commission to conclude that the neuro-physician had not attended on her during this period. But even then the commission held that there was no deficiency on part of2nd Opposite Party as the other doctors who were taking care were competent to treat her.
It was also held that the patient died because of brain damage due to clot arising from the heart valve, and the clot had occurred because of the fact that she never took anti-coagulation medicines as advised. The case was dismissed. [T. Rama Rao v. VijayaHospital& Anr., 1997 (3) CPJ 59 : 1997 (3) CPR 477(TN SCDRC).]
1.5 Cardiology-Heart attack-Death-No negligence-The husband of 1st complainant suffered heart attack and was admitted in the I.C.U. of 1st opposite party on 25.4.1993. It was alleged that due to negligence in treatment he died. The State Commission held that from the case sheet and the progress note and nurses' notes it was clear that proper care and treatment was provided. But, unfortunately due to second attack the patient died. In the absence of any other evidence the complaint was dismissed. The State Commission also held that the question whether the 1st opposite party should provide employment to the 1 st complainant or otherwise is beyond the purview of the C.P. Act. [Glare Devamma & Ors. v. Superintendent, AreaHospital& Anr., 1997 (3) CPJ 613 (AP SCDRC).]
1.6 Cardio-thoracic surgery-Post-CABG chronic osteomyelitis of sternum-Negligence held-Insurance company with whom Hospital was misused made liable to pay compensation. The complainant aged about 67 years underwent Coronary Artery Bypass Grafting (CABG) at Hinduja Hospital on 9.7.1991. During the post-operative period he developed severe lung infection, and subsequently pus started oozing out from the infection site. He was prescribed some antibiotics, but sinus developed, and ultimately on 30.9.1991, he was operated upon from removal of three wires which had got infected along with infected cartilage, but one wire was not removed, and the same was removed afterwards, after a period of one month. Even after one year he continued to have dressings for his operation wound.
The State Commission held negligence on the following grounds: patient developed infection in the hospital, and the hospital is responsible; .pus culture was done more than a month after purulent discharge started. The surgeon was very casual in his approach in prescribing the antibiotics; the contention that the third sternal wires were-removed later, as its removal would have affected the sternal stability is negated by standard text-book on Cardiac Surgery by John Kriklin and Brianbarrat Boyes; patient was later asked to discontinue the antibiotics despite the wound still oozing; and .the opinion of Dr. G.N. Rachmale of Sir J.J. Group of Hospitals that if the post-operative sternal infection was diagnosed early and treated vigorously it would not have become chronic; the certificates issued by Hinduja Hospital on 11.6.1993 and 24.6.1993 clearly showed that the Post-CABG status of the complainant was chronic osteomyelitis of the sternum. Rs. 50,000 was awarded for prolonged delay in prescribing antibiotics and getting pus culture done, Rs. 50,000 for the third operation for removal of third wire, Rs. 80,000 for medical expenses and Rs. 20,000 for the cost of the petition. Rs. 5,000 was awarded to Shri M.S. Kamath, who had ably assisted the State Commission in appreciating the medical aspects of the treatment. The Insurance Co., in terms of the policy obtained by the Hospital, was made liable to pay the compensation. [John Andradev. P.D.HindujaNationalHospital and Medical Research Centre & Ors., 1998 (1) CPR 579, (Mah. SCDRC).]