Arun Kumar Manglik versus Chirayu Health and Medicare
Private Ltd. & Anr. Civil Appeal Nos. 227-228 of 2019 (@SLP (C) Nos.
30119-30120 of 2016 dated January 9, 2019
Chronology of events
On 14th November, 2009, Madhu Manglik (spouse
of the appellant “Arun Kumar Manglik”; hereby referred to as “patient”), aged
56 years, was diagnosed with dengue fever. Lab report findings were:
“RBC- 4.21 million/cmm, Hb-12.1 gm/dL, TLC-1900/Cmm, Platelet Count 1.79
lakh/cmm, Dengue NS1 Antigen - Positive”.
The patient was admitted to Chirayu Health & Medicare
hospital at Bhopal (Respondent) to ICU on 15th November, 2009. She
was afebrile but reported accompanying signs of dengue fever including
headache, body ache and a general sense of restlessness. Her past medical
history was suggestive of cardiac complications (catheter ablation and
paroxysmal supra ventricular tachycardia).
On the day of admission, investigations carried out at
7.30 am revealed the following:
·
Hb 13.4
·
TLC 3000/Cumm
·
Platelet count 97000/cumm
·
PS for MP no malarial parasite seen
·
Blood urea 21 mg%
·
Serum bilirubin 1mg%
·
SGPT 521 U/L, SGOT 105 mg/dl
·
Sodium 140 meq/L Potasium 4.0 meq/L Ex R4
·
Urine test normal Ex R6
·
10.00 am – Pulse-88/min, Bp. 130/88 mm Hg
·
Temp. Afebrile c/o Pain in abdomen, hence
ultrasonography of the abdomen was carried out
At 2.00 pm: Pulse 128/min, mildly febrile, BP
110/70 mm Hg
By 6 pm, the BP was non-recordable, extremities were cold
and the pulse was non-palpable. The patient was administered IV fluids. She
developed bradycardia and cardiac arrest; 1.5 litres of extra fluids and
colloids were administered. Inotropes (dopamine and nor adrenaline) were given
to improve BP.
At 6.45 pm, she suffered a cardiac arrest
At 6.55 pm, she was examined by Dr CC Chaubey.
At 7.15 pm, another blood sample was taken; the results
were as follows:
·
Hb 8.1
·
TLC 7,400/Cumm
·
Platelet count 19000/cmm
·
Total protein- 3.9 gms%
·
A/G Ratio – 2
·
SGOT 169 IU/L
At 8 pm, the patient had a cardiac arrest.
At 8.50 pm: Patient
was declared dead.
Subsequent course of events
·
A complaint of medical negligence was filed before
the Medical Council of India (MCI). According to the Ethics Committee,
while treatment given was as per established medical guidelines, it was not
administered timely. In its order, dated 20th February, 2015, the
Ethics Committee observed:
“…..After perusing the statements given by both the
parties and documents on record in the case, the Ethics Committee discussed the
matter in detailed and noted that the patient admitted in Chirayu Health
& Medicare Pvt. Ltd., Malipura, Bhopal on the advice of Dr. A. Goenka but
he never visited in hospital to see the patient. The committee further noted
that treatment administered to the deceased in the hospital was correct as per
the medical guidelines but not given timely. Although, Dr. Goenka did not
went (sic)to hospital to see the patient as the patient admitted there as per
his assurance and advice, therefore, the Ethics committee prima facie found
that there is a professional misconduct on the part of both the doctors and
decided to issue a warning to Dr. A. Goenka and Dr. Abhay Tyagi with the
directions to be more careful in future while treating such type of
patients/cases”
·
The Appellant filed a complaint before the State
Consumer Disputes Redressal Commission (SCDRC) seeking compensation of Rs.
48 lakhs due to untimely death of his spouse due to the medical negligence of
the treating doctors at the hospital. The SCDRC found a case of medical
negligence and awarded a compensation of Rs 6 lakh together with interest at
the rate of 9% per annum (judgement dated 27th April, 2015).
·
The National Consumer Disputes Redressal
Commission (NCDRC) reversed the observations of SCDRC and dismissed the
claims.
·
The Appellant appealed before the Supreme Court
of India
Arguments of the Appellant’s Counsel
·
“…The hospital and the treating doctors failed to
follow the established protocol in treating a case of dengue;
·
The line of treatment was contrary to established
guidelines, formulated by the World Health Organisation, titled “Dengue
Guidelines for Diagnosis, Treatment, Prevention and Control”;
·
Except for the blood sample which was taken at
about 7.30 am, no further effort was made to determine the hematocrit levels
(HCT) during the course of the day and it was only when the patient suffered a
cardiac arrest after 6 pm that blood investigations were done at about 7.15 pm;
·
Admittedly, fluids were administered to the patient
as a part of the treatment protocol;
·
The administration of fluids ought to have been
accompanied by regular monitoring of blood levels which would have indicated
that there was a precipitous decline in the platelet counts and in the HCT
levels;
·
In the absence of regular monitoring, the treating
doctors were guilty of medical negligence. As a result of their negligence, the
doctors precluded themselves from receiving information in regard to the status
or progression of the disease;…”
Arguments of the Respondent’s Counsel
·
“The patient had been suffering from fever from
several days prior to her admission to the hospital. She was stable at the time
of admission
·
The patient did not go into a situation of a dengue
shock syndrome or hemorrhagic fever during the course of the day when she was
admitted to the hospital;
·
In such a situation, no requirement of regular
monitoring of HCT was warranted in accordance with the guidelines which have been prescribed by the Directorate of National
Vector Borne Diseases Control Programme (DNVBDCP);
·
The above guidelines, which have been prescribed by
the Union of India under the National Rural Health Mission, would indicate that
it is only in a situation involving dengue hemorrhagic fever or dengue shock
syndrome that further steps would be necessary;
·
The fluids which were administered to the patient
did not require a monitoring of the blood more than twice a day and it was only
in the evening that the HCT levels were required to be evaluated;
·
The patient had prior cardiac complications for
which she had been on an aspirin regime prior to admission to the hospital. She
was carefully monitored by a team of four doctors at the hospital;
·
The treatment protocol which was followed was
consistent with the guidelines which have been prescribed both by WHO as well
as by the National Vector Borne Diseases Control Programme;”
Observations of the Supreme Court
·
“…Between 14 January 2009 when the blood report of
the patient was obtained from Glaze Pathology Lab and the morning of the
following day on which she was admitted to the hospital, the platelet count had
recorded a precipitous decline from 1,79,000 to 97,000. This undoubtedly, as
the hospital urges in the present case, is a consequence of dengue. The patient
had tested positive in the Dengue Antigen test. At 7.30 am, on 15 January 2009,
her Hemoglobin was reported to be 13.4. The patient was thereafter placed on a
treatment protocol involving the administration of intravenous fluids.
·
The condition of the patient was serious enough to
require her admission to the Intensive Care Unit of the hospital. The hospital
has justified the administration of about 1200 ml of fluid between 7 am and 6
pm when she developed bradycardia and cardiac arrest.
·
The real bone of contention in the present case is
not the decision which was taken by the doctors to place the patient on a
regime of intravenous fluids which, for the purposes of the present appeals,
the Court ought to proceed as being on the basis of an established protocol.
·
The essential aspect of the case, which bears out
the charge of medical negligence, is that between 7.30 am when the patient was
admitted to hospital and 6 pm when she developed cardiac arrest, the course of
treatment which has been disclosed in the counter affidavit does not indicate
any further monitoring of essential parameters particularly those which could be detected by a
laboratory analysis of blood samples.
·
Since her admission and through the day, the
patient was administered intravenous fluids. The fluids were enhanced at 6 pm
by 1.5 litres after she developed cardiac arrest. The record before the Court
indicates that even thereafter, it was only at 7.15 pm that her blood levels
were monitored. The lab report indicated a hemoglobin level of 8.1 and platelet
count at 19,000. By then, the patient had developed acute signs of cardiac
distress and she eventually died within a couple of hours thereafter.
·
The requirement of carefully monitoring a patient
in such a situation is stipulated both by the guidelines of the World Health
Organisation (Clause 2.3.2.2) on which the appellant has placed reliance as
well as in those incorporated by the Directorate of the National Vector Borne
Diseases Control Programme in 2008 (Clause 7.1)…”
The Hon’ble Apex Court further observed:
“The issue is not whether the patient had already
entered a situation involving haemorrhagic fever or a dengue shock syndrome
when she was admitted on the morning of 15 November 2009. The real charge of
medical negligence stems from the failure of the hospital to regularly monitor
the blood parameters of the patient during the course of the day. Had this been
done, there can be no manner of doubt that the hospital would have been alive
to a situation that there was a decline progressively in the patient’s
condition which eventually led to cardiac arrest”.
This Court has consistently held in its decisions that
“the standard of care which is expected of a medical professional is the
treatment which is expected of one with a reasonable degree of skill and
knowledge. A medical practitioner would be liable only where the conduct
falls below the standards of a reasonably competent practitioner in the field.”
In several of its judgements (as below), the Supreme
Court has elucidated on the standards of care expected of medical
practitioners.
·
Bolam v Friern Hospital Management Committee
·
Dr Laxman Balkrishna Joshi v Dr Trimbak Bapu
Godbole
·
Jacob Mathew v State of Punjab
·
Indian Medical Association v VP Shantha
·
Nizam’s Institute of Medical Sciences v Prasanth S
Dhananka
·
Kusum Sharma v Batra Hospital and Medical Research
Centre
Conclusions of the Apex Court
In the practice of medicine, there could be varying
approaches to treatment. There can be a genuine difference of opinion. However,
while adopting a course of treatment, the medical professional must ensure
that it is not unreasonable. The threshold to prove unreasonableness is set
with due regard to the risks associated with medical treatment and the
conditions under which medical professionals function. This is to avoid a
situation where doctors resort to ‘defensive medicine’ to avoid claims of
negligence, often to the detriment of the patient. Hence, in a specific case
where unreasonableness in professional conduct has been proven with regard to
the circumstances of that case, a professional cannot escape liability for medical
evidence merely by relying on a body of professional opinion.
In the present case, the record which stares in the face
of the adjudicating authority establishes that between 7.30 am and 7 pm, the
critical parameters of the patient were not evaluated. The simple
expedient of monitoring blood parameters was not undergone. This was in
contravention of WHO guidelines as well as the guidelines prescribed by the
Directorate of National Vector Borne Diseases Control Programme. It was the
finding of the Medical Council of India that while treatment was administered
to the patient according to these guidelines, the patient did not receive
timely treatment. It had accordingly administered a warning to the respondents
to be more careful in the future. In failing to provide medical treatment in
accordance with medical guidelines, the respondents failed to satisfy the
standard of reasonable care as laid down in the Bolam case and adopted by
Indian Courts.”
The Court found the judgement of NCDRC to be
“unsustainable” and held that “There was no basis or justification to
reverse the finding of medical negligence which was arrived at by the SCDRC.” It
did not find the Director of the hospital to be personally liable for the
medical negligence, although it found the hospital to be liable for medical
negligence. “…Hence, while the finding of medical negligence against the
hospital would stand confirmed, the second respondent would not be personally
liable.”
Compensation awarded
The Supreme Court observed that “While quantifying the
compensation, the SCDRC was in error in holding that since the son and daughter
of the appellant are “highly educated and working” and had not joined as
complainants, the complainant himself would be entitled to receive compensation
only in the amount of Rs. 6 lakhs.”
“…it is now well settled by a catena of decisions of this
Court that the contribution made by a non-working spouse to the welfare of the
family has an economic equivalent. In Malay Kumar Ganguly v Sukumar Mukherjee, Justice S B
Sinha held thus:
“172. Loss of wife to a husband may always be truly
compensated by way of mandatory compensation. How one would do it has been
baffling the court for a long time. For compensating a husband for loss of his
wife, therefore, the courts consider the loss of income to the family. It may
not be difficult to do when she had been earning. Even otherwise a wife's
contribution to the family in terms of money can always be worked out. Every
housewife makes a contribution to his family. It is capable of being measured
on monetary terms although emotional aspect of it cannot be. It depends
upon her educational qualification, her own upbringing, status, husband's
income, etc.”
Thus, in computing compensation payable on the death of a
home-maker spouse who is not employed, the Court must bear in mind that the
contribution is significant and capable of being measured in monetary terms.
“We accordingly, direct that the appellant shall be
entitled to receive an amount of Rs. 15 lakhs by way of compensation from the
first respondent. The compensation, as awarded, shall carry interest at the
rate of 9 per cent per annum from the date of the institution of the complaint
before the SCDRC until payment or realisation. Payment should be effected
within two months.”
|
Discussion on the case
In dengue,
people do not die of low platelets but of capillary leakage. In this case,
capillary leakage occurred around 2 PM as evident by inappropriate
tachycardia. Missing this is a common mistake in a clinical situation even in
the best of the centers. In this setting, one will find low pulse pressure
(the difference between SBO and DBP will be < 20 mm Hg). Without wasting
time, one should infuse 20 ml / kg of fluids bolus at this juncture and then
go on infusing fluids ( 150 ml per hour) till the patient passes urine (
adequate hydration)
With
leakage, the hematocrit will rise rapidly and will fluids it will normalize.
One may not waste time in getting the investigations done; simple pulse
pressure and tachycardia monitoring may be sufficient in smaller setups.
·
Is it criminal negligence? No; no
intention, no knowledge
·
Is it a difference of opinion? No, line
of treatment is standard
·
Is it an error of Judgment? Yes, one
often misses tachycardia in presence of fever
·
Did this patient die of low platelets? No clear
cut evidence
·
Did this patient die of leakage? Looks
like
·
Was the death preventable? Once
leakage has occurred the mortality is high
·
How to prevent? Make sure that a patient
with dengue passes urine every few hours (adequate hydration)
·
What are the clinical signs of leakage? Sudden
onset of weakness with high heart rate
·
Is the compensation justified? Will
depend on the arguments
·
Is the amount of compensation justified? Yes, if
compensation is awarded
|
Dr KK
Aggarwal
Padma
Shri Awardee
President
Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group
Editor-in-Chief IJCP Publications
President
Heart Care Foundation of India
Past
National President IMA
No comments:
Post a Comment