A ‘stitch’ in ‘time’ saves (doctor) nine!

Contemporaneous medical records play a vital role in establishing the sequence of events in the court of law, and can be a great aid to a doctor defending himself against alleged medical negligence. Also, while practicing evidence based medicine in accordance with current medical literature, documenting the same is very important. In this regard, the case – Balabhai Nanavati Hospital & Anr Vs B.D. Singh & Anr – decided by the National Consumer Disputes Redressal Commission (NCDRC) in May 2016 provides some important insights for doctors.

In this case, a middle-aged male was brought to the hospital with crush injury of foot. The patient underwent debridement and fracture-fixation, and, subsequently, foot amputation (Syme’s amputation) due to gangrene was performed. There was a possibility of further amputation surgery, however, the patient sought discharge and shifted to another hospital. The patient sued the hospital and Orthopaedic surgeon in State Consumer Disputes Redressal Commission (SCDRC) on the grounds that – (a) The first surgery was delayed unreasonably (by 5 hours) which led to amputation (b) Three amputations were performed without adequate consent (signatures taken without proper counselling). The SCDRC ruled in favour of the patient and awarded a compensation of Rs. 6 Lacs with 9% annual interest (for about fourteen years). The hospital and the surgeon appealed in the NCDRC against the verdict. The NCDRC, after going through the case records, overturned the order of the SCDRC and ruled in favour of the hospital and surgeon. While judging ‘no negligence’ in this case, the NCDRC made the following observations –

1)—Patient was brought to the hospital at 10:30 AM, and, as per the time mentioned in the medical records, treatment with i.v. fluids was initiated immediately at 10:30 AM, while admission formalities were completed at 11:18 AM.

2)—Separate consents were taken for fracture-fixation, debridement and amputation, and, in addition to the patient, the relatives had also signed the consents, which suggested that the consents were well-informed and adequate.

3)—Court appreciated the fact that exact details of all surgical procedures were well-documented in the medical records.

4)—The NCDRC referred to Mercer’s Textbook of Orthopaedics and Trauma, and Rockwood and Green’s Fracures in Adults to verify whether the treatment adopted by the surgeon was standard or not. NCDRC concluded that the line of treatment was in accordance with that prescribed in the standard text-books. The NCDRC also noted that the patient was taken to the operation theatre within 6 hours for debridement, as prescribed in the text-book.

Thus, the importance of time documentation is clear. In the above case, the temporal sequence of events factually established by the time-label on medical records suggested that the patient was not neglected. It is always a good practice to take signature of the patient’s relative on the consent form, in addition to his own. Preferably, the pre-consent counselling should be audio-visually recorded under camera, so as to avoid allegations of ‘no counselling’ later on. Doctors should never deviate from practicing evidence-based medicine, as prescribed by standard text-books.

This particular paragraph from Mercer’s Textbook of Orthopaedics and Trauma (pg. 395), which the NCDRC also cited, should be noted – “When the degree of destruction does not justify early amputation, experience is required to judge the advantages of early amputation and prosthetic fitting against prolonged surgical efforts with a dubious end result and limited recovery. A second opinion is immensely helpful especially in the present era of increasing litigation and should be considered.”

Do I need to say anything more?

(This write-up is only a general advisory and not a substitute for qualified legal opinion. Reader discretion is therefore recommended. If you find this write-up useful, please share it with your doctor-friends. TechnoScope Systems is a venture by doctors, for doctors. To know more about how we can assist you, please visit our website. You can write to the author at: sohonica@gmail.com)