Damned if you do, damned if you don’t – A medicolegal example

Small and medium-sized hospitals (SMSHs), which form the lifeline of healthcare in India, are going to find it increasingly difficult to manage themselves. In addition to the increasing regulations in healthcare, the behaviour of the society towards doctors and SMSHs is changing. I discuss a case here – Care Hospital & Ors Vs Surisetty Sannibabu & Ors, decided by Andhra Pradesh State Consumer Disputes Redressal Commission (SCDRC) in 2013 – which illustrates some of the practical problems faced by hospitals in India, particularly the small and medium-sized hospitals.

A 50-year old lady was taken to a Physician at a well-known corporate hospital (hereinafter referred to as hospital ‘A’) with complaints of chest pain. Angiography was performed and coronary artery disease requiring CABG was detected. Patient was referred to a Cardiovascular surgeon in the same hospital (hospital-A). After consultation, the surgeon and patient’s kin agreed to admit the patient for surgery to another hospital (hereinafter referred to as hospital ‘B’), since hospital-B offered a cheaper surgical package. The patient was subsequently operated at hospital-B, and in the post-operative period she developed fever, epistaxis, hypotension and renal failure, due to which the patient expired on 14th post-operative day. In the discharge summary, hospital-B mentioned cause of death as - “CAD Post-CABG, Epistaxis, Malaria, Pancytopenia, Septic shock, Acute Renal Failure, Metabolic Acidosis.” Following the death of the patient, a mob gathered outside the hospital in protest and even the Deputy Mayor of the city intervened at the patient’s behest. The hospital, under pressure, refunded Rs. 50,000 out of the total bill of Rs. 80,000 (only medicines and materials charged). The patient’s kin alleged negligence and filed a complaint each in Medical Council, police station and District Consumer Disputes Redressal Forum.

The main contentions of the patient’s kin were –

– The doctors did not conduct proper pre-operative investigations at hospital-B, but rather relied on reports from hospital-A.

– In the post-operative period, the doctors ignored the patient’s deteriorating condition and delayed investigating the patient.

– Hospital-B ignored the treatment suggested by the General Physician (arranged from a different hospital at the behest of the patient’s kin, who had insisted upon him examining the patient).

– No proper treatment was given for jaundice. Neither a Nephrologist was consulted for renal failure, nor dialysis or renal transplant considered for treatment.

– The patient was tortured by tying-up her hands and legs with bandage.

– Date on one lab report was manipulated i.e. the numerical ‘4’ was altered to ‘6’ to show the date as 26 instead of 24 to hide the non-treatment of septicaemia.

– The hospital refused to send the body for post-mortem.

The District Forum found the doctors and hospital negligent, and thus awarded compensation of Rs. 2,00,000.

Both the parties challenged the order of District Forum in State Forum (SCDRC). While defending themselves, the doctors and hospital said that all investigations were conducted appropriately, and treatment for Malaria was given. Hospital claimed that it had even reduced the surgical package fees by 20% after one MLA insisted on giving concession to the patient. This was in addition to the Rs. 50,000 refund after the patient’s death. The surgeon quoted textbook of Cardiac Surgery written by Kirkin Barrath-Boyes to establish that the patient was a high risk candidate on account of being a female having disease in left main coronary, and a pre-operative high-risk consent had been sought accordingly. The surgeon referenced the text book to claim that post-operative early mortality is a known complication with high-risk cases. The surgeon denied the allegations of delay in investigations or consultations, claiming prompt consultations were sought from ENT Surgeon, General Physician and the other physician insisted upon by the patient’s family. The surgeon further explained that the acute-onset jaundice was due to haemolysis and not due to infection or use of unsterile syringes, as alleged by the patient. The surgeon referenced the textbook ‘Surgery of the Chest’ by David Sabiston Jr to defend his point that dialysis or transplant was not authoritatively the solution. The surgeon also denied the allegation of deliberate change of date on the lab report, saying that the date of the report was mentioned in multiple documents and hence changing date in one document would serve no purpose. The surgeon explained that the hands and legs of the patient were tied to prevent violent movements in the state of altered sensorium, and not for torturing her. The surgeon said that the very fact that Medical Council conducted an inquiry and did not take any action itself established no negligence on the part of doctors. The hospital claimed that post-mortem was not conducted since the Deputy Mayor made a request for the same on behalf of the patient.

The SCDRC found that this was prima facie a case of a lady with no pre-operative health ailment (as revealed from pre-operative investigations) except for coronary artery disease, dying within two weeks of surgery due to malaria and septicaemia. Therefore, the burden to proof shifted to doctors. The SCDRC observed that the lady had not died due to cardiac complications but rather due to malaria and septicaemia, and the doctors had failed to explain how a cardiac patient developed malaria followed by septicaemia and renal failure when she was admitted in ICU. Merely stating that the patient was a female and had left main coronary disease was not sufficient. The SCDRC also said that the fact that the patient contracted malaria in the ICU of the hospital was evidence of low hygienic conditions in the hospital. The SCDRC pronounced the doctors and hospital guilty of negligence, added extra compensation of Rs. 3,00,000 towards loss of companionship, love and affection to the patient’s relatives, thus enhancing the total compensation to Rs. 5,00,000.

This case brings into light some important facts –

i)—Hospitals, particularly small and medium-sized, are increasingly facing interference by politicians, especially for concessions, discounts and even for waving-off charges. However, hospitals and doctors should remember that refunding or waving-off fee in case of adverse patient outcomes is likely to be perceived as admittance of guilt by a lay person. Refunding money does not preclude the patient from claiming compensation or filing a police complaint.

ii)—Courts and consumer forums are increasingly looking at the infrastructure facilities, or the lack of them, in hospitals, with respect to the perceived status of the hospitals. Lack of adequate infrastructure facilities, including but not limited to competent staff, machinery, patient-safety measures and sterilisation standards etc. are being assessed while deciding cases of negligence. In the case discussed above, the SCDRC’s conclusion that the patient contracted malaria despite being admitted in ICU decidedly went against the hospital.

iii)—If clinically indicated, never hesitate to order an investigation or consultation. Saving a few bucks may prove very costly. If patient refuses to get it done, write that in so many words on the case sheet. Keep the records clear and avoid corrections and overwriting.

iv)—Damages awarded in cases of medical negligence can be pecuniary and non-pecuniary. In addition to specific damages, compensation can also be awarded towards loss of companionship, love and affection (in case of a deceased patient).

(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)