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--------------- Print Magazine --------------
  May 2016
  April 2016
CASE STUDY - By Anoop K. Kaushal
Discharge Summary should not be prepared without consulting the Operating Doctor

Original Petition No. 2 of 2000 decided by the National Consumer Disputes Redressal Commission on 08-09-2010.

The version of the patient was that she experienced breathing problem on or around 29-12-1997 and consulted a general physician, who advised her to get herself examined by an ENT specialist. She approached opposite party No.1-an ENT Specialist who advised her to get admitted in the nursing home for "Nasal Polypectus operation". She was admitted in the nursing home-opposite party No.2 on 31-12-1997 and on the said date "SMR (Submucousal Resection) operation" was conducted on her and she was discharged from the nursing home on 01-01-1998. From the discharge summary the complainants came to know that instead of "Nasal Polypectus Operation", the Doctor conducted "SMR Operation". On 04-01-1998 she developed serious complications and in the night of 05-01-1998 CSF (Cerebro Spinal Fluid) started flowing from the nose, resulting in severe headache, throat pain, cough and neck pain besides fever and cold. Dr. Satchidanand Das at Siliguri diagnosed her problem to be the case of Coryza on the basis of discharge slip. On 23-01-1998 the patient got herself admitted in Malar Hospitals Limited, Chennai for further treatment and was discharged on 18-02-1998. Intra Nasal Etcmaidectomy Operation was done on both sides of nose of the patient and she was alright. The complainant filed the complaint praying for a compensation of Rs.35,62,753 on alleged medical negligence on the part of opposite parties.

The operating surgeon denied that any SMR operation was ever done on the patient and that only polypectus operation was done. The Nursing Home also stated the same but admitted that the discharge summary prepared by their Resident Medical Officer erroneously described the surgery as SMR instead of Nasal Polypectomy.

As per record, the very first prescription issued by the Doctor on the 29th of December, 1997, when the patient met the surgeon for the first time, after examination clearly stated that her case was that of a nasal polyp. On seeing the x-ray report on the next day it was decided to have her operated. The referral note addressed to the Princep Nursing Home clearly states "Please admit Ms. Uma for Nasal Polypectomy .. under GA at 7.30 AM on 31-12-1997". The reply filed by the Nursing Home admitted that the endorsement of SMR operation on the discharge letter was clearly a mistake of their Resident Doctor who had prepared the discharge letter without consulting the operating surgeon and also from the prescription of the neuro surgeon, whom the complainants had consulted at Siliguri. It was held that the Doctor had diagnosed the case of the patient to be that of a nasal polypectus and required polypectomy and not SMR.

On post-operative care the complainant contended that the operating Doctor even on the very next day of the operation while removing the bandage had noticed some watery discharge from the nose but did not take serious note thereof and when the patient complained of similar discharge with other complications on the 3rd of January, 1998, the Doctor only prescribed some medicines and gave her the clearance to go back to her native town.

According to the Doctor it was the patient who was in a hurry to go back to her native place and had requested the Doctor for urgent operation and treatment. Medical Literature of Royal United Hospital Bath was relied upon and it was observed that risks in the operation of the polypectomy are very rare but once they appear they tend to be serious. Held, explanation (of the Doctor) appears quite convincing for the simple reason that a nasal polypectus operation is very minor in nature and does not necessarily entail long hospitalisation as an indoor patient in a clinic.

It was further observed that the complainant had failed to level any serious allegation against the Doctor that in the process of conducting polypectomy his instruments have entered in the surrounding areas of the skull, which was the main cause of the CFS leak and there was no expert evidence that in the process of polypectomy the Doctor had been negligent.

Order: The discharge summary was prepared by the Resident Doctor who made not only a mistake but a mistake of very serious nature, wherein as against polypectomy operation it has been stated that SMR has been conducted. This had the effect of misleading the Doctors who subsequently came into the picture during her post-operative phase. It has also made the patient believe that the Doctor even though diagnosed her case to be that of nasal polypectus erroneously conducted SMR operation. We hold the Nursing Home directly responsible in allowing a junior Resident Doctor, who appears to have joined the
Nursing Home on that very day, to prepare the discharge summary and that too without consulting the operating Doctor. The least that was expected of the nursing home was that after the junior Doctor had prepared the discharge slip it ought to have been countersigned either by the operating Doctor or the Superintendent of the Nursing Home and patient should not have been issued the slip straightaway. Making a totally wrong mention of the surgery undertaken in the discharge slip is a serious lapse which cannot but be termed as an act of negligence on the part of the nursing home and in view thereof we consider it appropriate to award a compensation of Rs.20,000/- to be paid by the nursing home.

Anoop K. Kaushal, Advocate - kaushal@justice.com
(Print Version)
Rs. 600/- per year
(Registered Post & Courier)

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