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--------------- Print Magazine --------------
  May 2016
  April 2016
CASE STUDY - by Anoop K. Kaushal

Post-mortem report and res ipsa loquitor

Jangamgunta Balasubramanium v. Dr. Atluri Ravindranath

First Appeal No. 203 of 2007, pronounced by the National Consumer Disputes Redressal Commission, New Delhi on 4 th September, 2012.

Facts: The Appellant No.1's wife, Smt. J. Madhavi, the 'patient' conceived for the second time and underwent regular medical check-ups upto the sixth month of pregnancy in Chennai where Appellant No.1 was informed that her condition was normal. In her seventh month of pregnancy, patient went to her parents' home in Vijayawada and was under the medical care of Respondents No.1 and 2. On 1-8-2000, she was admitted in Respondent No.1's Nursing Home and underwent a caesarean section on 2-8-2000 and delivered healthy twin babies. In the evening of 3-8-2000, there was gushing of fluids from the stitches of the surgery site as also blockage of urine and Appellant's father-in-law informed the Respondent No.1 who after examining her referred her to a Radiologist (Respondent No. 6) and thereafter informed Appellant's father-in-law that a re-operation was necessary because complications had developed due to mounting pressure upon the kidneys because of the twin pregnancy. Respondents No. 1 and 2 conducted an Exploratory Laparotomy on 4-8-2000 and thereafter the patient was admitted in Aruna Kidney Centre for dialysis as advised by Respondent No. 4, who was a Nephrologist. Since her lungs had also got affected, Respondent No. 4 referred the patient to Respondent No. 5 and Respondent No. 6 and thereafter she was admitted in Respondent No. 6's hospital where she was put on ventilator and sent every two days to Aruna Kidney Centre for dialysis. However, patient's condition continued to deteriorate and she died on 7-8-2000. A post-mortem conducted by a team of three doctors concluded that the cause of the death was Septicaemia resulting from post-operative complications.

Defence : Respondents denied that there was any medical negligence in this case and stated that the complications may have arisen after the patient was admitted in Aruna Kidney Centre since the laparotomy conducted following leakage of fluids did not reveal any urological problem. It was only re-confirmed that the patient was having pregnancy complications such as eclampsia and kidney failure because of which a Nephrologist was also consulted. Further, neither the post-mortem report nor the criminal complaint filed against Respondents indicated any medical negligence on their part. Other Respondents i.e. Respondents No. 3, 4, 5 and 6 stated that by the time they had seen the patient, she was already in a critical condition and despite being given the best intensive care which included dialysis and ventilator support, patient could not be saved.

Findings of State Commission: The State Commission after hearing both parties and on the basis of evidence filed before it concluded that a case of medical negligence was made out only against Respondents No. 1 and 2 who conducted the caesarean operation, tubectomy and subsequently the laparotomy.

"When the pregnancy is admittedly a twin pregnancy, opposite parties 1 and 2 ought to have shown reasonable care and caution which a doctor should according to normal medical standards and taken proper care and caution while conducting the surgery, especially, when opposite parties 1 and 2 were well aware of the complications of the surgery consequent to the operation. The opposite parties admit that "the cause for urinary blockage is not found". It is held by the National Commission in Savita Garg v. National Heart Institute reported in Supreme Court and National Commission Judgments on Medical Negligence and Insurance Vol.II page (1) that it is the duty of the hospital and the treating doctor who should explain the line of treatment given and the burden of proof is also on them to prove that they were not negligent and that they have followed the normal medical practices as per standard medical parlance. At the time of admission, the case sheet of opposite parties 1 and 2 also does not state that the patient is a high risk one. Here, neither the case sheet nor the material evidence filed explains the cause for the fluid leakage or the urinary blockage. Except for stating that there was no injury to the bladder which is contrary to the post-mortem report, no satisfactory explanation has been given by opposite parties 1 and 2, for which act, we are of the considered opinion that they are negligent."

Held: The fact that the patient was pregnant and that the delivery was through caesarean section is not in dispute. It is also a fact that following the surgery, the patient for the first time had urine leakage as also urinary blockage which indicated that there was a problem with the bladder. This problem aggravated over the next one month leading to several complications and finally Septicemia leading to multiple organ failure and death. The fact that there was an injury to the bladder which caused leakage of urine has been confirmed by the post-mortem report which clearly states that there was an incised wound measuring 1.5 cm which sutured and partially healed and leakage of urine was seen from the wound right upto the time of death. Since this could have only occurred during surgery, there is an obvious nexus between the caesarean section conducted by the Respondents and subsequent problems with the bladder. We, therefore, agree with the State Commission that there is sufficient and credible evidence to prove that this injury occurred during the course of the surgery. Further, the Respondents' contention that patient was a high risk case with pre-eclamsia condition is nowhere noted in the case history. Among the principles applied in such cases of negligence are whether a doctor would have done or have failed to do something which in the given facts and circumstances, no medical professional will do; and whether the negligence was so manifest and demonstrative that no professional or skilled person in the ordinary sense and prudence could have indulged in. In the instant case, applying these two principles, the Respondents were undoubtedly guilty of medical negligence because during the course of a caesarean operation, they caused injury to the urinary bladder leading to multiple complications and death which was totally avoidable had due care been taken especially since caesarean sections are fairly common surgical procedures. Respondents No.1 and 2 who had conducted the surgery have not been able to satisfactorily explain the post-operative complications and their contention that the patient was seen by four other doctors including a Nephrologist implying that complications could have occurred because of their treatment does not inspire any confidence since no surgery was conducted by any of these doctors. In view of the above circumstances, applying the principle of res ipsa loquitur, no expert opinion is required to prove the apparent medical negligence in this case.

Appellants have sought enhanced compensation keeping in view the loss suffered by the family because of the death of a young mother and wife. The State Commission had awarded ` 4 lakhs as adequate compensation keeping in view all the facts of the case including age and status of the patient as also the loss suffered which can only be notionally quantified. We have considered this matter and are of the view that since three young children have been rendered motherless, two of them at infancy, and in the interest of securing their future, there is a case for enhancing the compensation. We, therefore, direct that the compensation of ` 1 lakh given to each of the three minor Appellants be enhanced by ` 50,000 each and the total amount of ` 1,50,000 each be put in the name of the minor Appellants in a Nationalized Bank under fixed deposits till they attain the age of majority.

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