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--------------- Print Magazine --------------
  May 2016
  April 2016
CASE STUDY - By Anoop K. Kaushal
Dr. (Mrs.) V.C. Bendale
Leela Veerajaneyulu

Revision Petition No. 586 of 2006 pronounced by the National Consumer Disputes Redressal Commission, New Delhi, vide Order dated 16th December, 2010.

Respondent/complainant approached Dr. Bendale for the treatment of her ailing son on the 30 th of September, 1997 who after examination prescribed the medicines of Surpoxin and Reziz. The child recovered from the ailment i.e. fever within 2-3 days and started going to the school. However, when the child complained of redness and watery eyes the parents again approached Dr. Bendale who prescribed Pyrimon eyedrops on the 14 th of October, 1997. The main problem, however, arose when on the 15 th of October, 1997 the child started running high fever, his eyes continued to be red and watery and in addition rashes had appeared on the chest and back and Dr. Bendale, therefore, had to be approached for the third time. While Dr. Bendale contended that she advised the parents to take the child to a Pediatrician (child specialist) the parents insisted on the child being treated by her and, therefore, she continued with the earlier treatment for Malaria, including the administration of Reziz. However, when the child was administered 1 tablet of Reziz, as advised by Dr. Bendale, severe rashes developed all over his body within half an hour and, therefore, the doctor was again approached for the second time on the same day. Dr. Bendale, thereafter, referred the patient to one Dr. P.M. Gandhi, a child specialist. The child, accordingly, was taken to the Gandhi Hospital and was examined by Dr. Gandhi, who diagnosed the problem to be that of SJS and advised hospitalization. When the parents expressed their inability to get the child admitted on the spot, he prescribed some medicines. The child, however, was admitted on the next day i.e. on 16 th of October, 1997 and remained under the care and treatment of Dr. Gandhi for a day and was taken to the Naval Hospital "INHS Asvini" for better management as the complainant's husband was an ex-serviceman. The doctors at Naval Hospital confirmed it to be a case of SJS and tried their level best to treat the patient, who, however, unfortunately expired on 24 th of October, 1997. Cause of death was stated to be cardiac arrest as a consequence of SJS. It was alleged by the complainant that Dr. Bendale, who first treated the child was responsible for the development of SJS, ignoring the fact that the child was less than nine years old and according to the suggested/recommended dose for administration of Reziz a high doze of the medicine was recommended and further when rashes had appeared on the body of the patient on the 15 th of October, 1997, it was clear indication that the child was developing SJS, Dr. Bendale should not have repeated the administration of Reziz, which aggravated the condition of the child to develop into a full fledged SJS.

The District Forum vide its detailed order held that the allegations did not stand substantiated and dismissed the complaint. The State Commission on appeal set aside the order of the District Forum and allowed the complaint directing Dr. Bendale to pay a sum of Rs. 2,60,000 with 7% interest.

According to the petitioner the Pediatrician diagnosed the case to be that of SJS without proper diagnosis and the doctors at INHS without carrying out any investigation took it for granted that it was a case of SJS. It was further argued by the doctor's side that Malaria is rampant in the area to which the child belonged and even as per the advice of the State Government the doctors are to treat any case of fever as being Malaria and start treatment. Prescribing Reziz for the treatment of Malaria was, therefore, in keeping with the practice prevailing in the area.

OBSERVATIONS : The minimum that Dr. Bendale ought to have done was to have examined the child properly to arrive at, even on clinical examination, that he was suffering from Malaria. However, the prescription does not indicate the age of the child nor does it indicate as to whether he was running fever at the time of examination and whether there were other symptoms from which she could arrive at a proper conclusion that the child was suffering from Malaria. Fever has manifestation e.g. viral, dengue, chikangunia etc. and the doctor should have recorded some details as to why she straightaway diagnosed it to be a case of Malaria. Blood smear tests facilities are now-a-days available in every PHC and health center and she should have asked for a test report before prescribing medicine without that. She has not stated a single word with regard to the history of the patient and has gone on to prescribe the medicines in a very routine manner. Her contention that she has diagnosed it to be a case of Malaria is now based on the prescription of Reziz rather than on any clinical history. This by itself constitutes negligence. However, even if the case is taken to be that of Malaria, straightaway prescribing Reziz without any investigation will not be justified.

The treatment protocol under the National Drug Policy of the Government of India prescribes the following steps for the treatment of Malaria :-

" Treatment of uncomplicated malaria:

1. All fever cases suspected to be malaria should be investigated by microscopy or RDT.

2. P.vivax cases should be treated with chloroquine for three days and Primaquine for 14 days. Primaquine is used to prevent relapse but is contraindicated in pregnant women, infants and individuals with G6PD deficiency.

Note: Patients should be instructed to report back in case of haematuria or high colored urine /cyanosis or blue coloration of lips and Primaquine should be stopped in such cases. Care should be taken in patients with anaemia.

3. P. falciparum cases should be treated with ACT (Artesunate 3 days + Sulphadoxine-Pyrimethamine 1 day). This is to be accompanied by single dose primaquine on day 2.

4. Pregnant women with uncomplicated P. falciparum should be treated as follows:

  • 1st Trimester: Quinine
  • 2nd & 3rd Trimester: ACT

Note: Primaquine is contra indicated in pregnant women.

5. In cases where parasitological diagnosis is not possible due to non-availability of either timely microscopy or RDT, suspected malaria cases will be treated with full course of chloroquine, till the results of microscopy are received. Once the parasitological diagnosis is available, appropriate treatment as per the species, is to be administered.

6. Presumptive treatment with chloroquine is no more recommended. " (emphasis added)

Further reliance was made on the medical literature which stated that Reziz is a combination of two drugs such as Sulphadoxine and Pyrimethamine. No doubt, it is used to treat Malaria but only if it has been established that Malaria is chloroquine resistant and the attack is acute in nature. With regard to the dosage, it stated that while adults can take 2-3 tablets as a single dose, the children from 5-10 years age group with 20-30 kgs. body weight can be given 1½ tablets as a single dose. It clearly stipulates that the dose should not be repeated for at least seven days.

HELD: Dr. Bendale has prescribed four tablets of Reziz at the rate of two tablets per day for two consecutive days as against the recommended dose of 1½ tablets as a single dose. It cannot, therefore, be said that the dosage prescribed was not in excess. It is admitted that even on the 15 th of October, 1997 Dr. Bendale has repeated Reziz and, therefore, it is fully established that Reziz had been administered to the child far in excess of the requirement. In this background, the attempt of the learned counsel for Dr. Bendale that the child was not suffering from SJS is only a desperate attempt to pass on the blame to the doctors of the INHS. Dr. Gandhi, the Pediatrician, with a vast experience behind him and the specialist doctors at INHS have held this to be a case of SJS pursuant to the excessive dose of Reziz and we are not convinced that in the absence of any confirmatory diagnostic test they have in any way gone wrong in diagnosing the case to be that of SJS. It is not denied that Reziz can cause SJS and medical literature shows that it is potentially fatal and there are possibilities of death in case of adverse effect. In Malaria programme this medicine is not recommended in routine but is prescribed very cautiously with other medicines. Dr. Bendale having not prescribed the proper medicine with proper dosage has failed in her duty as a doctor and the State Commission, in our view, has very rightly held her to be negligent.

The revision petition filed by the doctor was dismissed.

Anoop K. Kaushal, Advocate - kaushal@justice.com
(Print Version)
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