Case Study

CLINICAL EXAMINATION AND NECESSITY OF pre-operative TESTS

Smt. Vimla Rana v. Mahesh Hospital, Consumer Case No. 230 of 2014 decided by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi  on  01 Dec 2017.


Facts: The daughter of the complainant was admitted to opposite party No.1 Mahesh Hospital on 27.6.2012 in a very critical condition with complaint of severe abdominal pain for last six days and nausea and vomiting for two days.  At the time of admission, her BP was not recordable and she was shivering.  Before taking her to the Mahesh Hospital, the complainant had taken her for an ultrasound test at Suvidha Diagnostic Centre, which had found a well-defined Heterogenous Adnexal mass of 60×47 cm in the right Adnexa.  She was admitted in emergency and exploratory laparotomy was performed on her at 12.00 noon. As per the finding in the procedure, she was suffering from miliary Tuberculosis all over her intestine with plastic adhesions and multiple perforations in the intestine.   She was discharged from Mahesh Hospital on 28.6.2012 and was admitted to LNJP hospital.  She died in LNJP hospital on 14.7.2012.  Alleging medical negligence in the treatment of her daughter, the complainant seeking compensation quantified at Rs.1.00 crore, alleged that the relative of the complainant had objected to the opening of the stomach of the deceased without conducting proper medical test and ultrasound.  It was also alleged that ICU and ventilator facility was not available in the hospital nor was there proper light in the operation theatre.  It is also alleged that the hospital did not have proper nursing staff and ward boys.

Defense: That Mahesh Hospital is a well-equipped modern center, duly registered with Directorate of Health Services and opposite party No.2 Dr. Mahesh Aggarwal was a qualified and experienced Surgeon, practising for the last 32 years. When the daughter of the complainant was brought to the hospital her pulse was not palpable and her BP was not recordable. Generalized tenderness with rigidity and guarding was present all over the abdomen and she was diagnosed as a case of Peritonitis with Septic Shock Infection and pus in abdominal cavity with widespread toxins / poison in the blood, that her ultrasound had shown a right side Heterogenous Adnexal Mass measuring 60 x 47 mm, probably an Ovarian Cyst.  After explaining her condition to her mother, the family members were asked to whether they would like to take her to a higher center such as LNJP hospital.  Considering the condition of the patient, they decided to admit her in Mahesh Hospital, she was operated and Exploratory Laparotomy was done which revealed extensive miliary tuberculosis in the intestine with multiple perforations and faecal peritonitis, all perforations were closed and thereafter the abdomen was closed in layers after leaving the drain, patient was thereafter conscious, and oriented, her uncle was told that she might require referral  and dialysis but the family decided to wait till morning, patient was then transferred to LNJP hospital.  As per the documents of LNJP hospital, the patient was not well for last 3-4 months and had abdominal pains, besides fever and loss of weight. The complainant had made a complaint against Dr Mahesh Aggarwal to Delhi Medical Council which referred to matter to its Ethics Committee.  The Medical Council, vide its order dated 31.5.2013, held that prima-facie no case of negligence was made out on the part of the Doctor Mahesh Aggarwal in the treatment administered to the daughter of the complainant at Mahesh Hospital, appeal before MCI was also dismissed.

Expert Witnesses: Dr. Pammi Chawdhry of LNJP hospital, simply proved the MLC of the deceased and did not say a word about the alleged negligence.     Dr. Pawanindra Lal, Professor of Surgery in LNJP Hospital was Co-Unit Head of the Surgical Unit with Dr. N.S. Hedke and the deceased daughter of the complainant was under the treatment of their unit at LNJP Hospital, that exploratory laparotomy is an operation conducted in emergency to explore the abdominal cavity with an intent to find the cause of acute abdomen.

Q. Is any investigation required before undertaking exploratory laparotomy?
Ans. Some investigations may be undertaken before such an operation however a large number of times, it is the clinical findings in combination with blood reports that may suggest the diagnosis of acute abdomen requiring an exploratory laparotomy.  Thus, it is not always necessary to get any investigations done before undertaking this procedure, though if he feels necessary, the doctor may require further investigations before undertaking the procedure.

Q. Is it correct that on account of MRI Scan and CT scan having become available, these investigations should have been done before this procedure?
Ans.  It is not correct.
Considering the condition of this patient it was advisable to undertake this procedure only in a hospital equipped with an ICU.

Q. Considering the record of the treatment of this patient at the previous hospital, do you find any negligence in her treatment in the previous hospital?
Ans.  Considering the condition in which the patient came to this center, exploratory laparotomy was the right procedure to be performed on her and I do not find any negligence on the part of the previous hospital in treatment the patient.

Q.  What is the meaning of Miliary Tuberculosis?
Ans.  Miliary Tuberculosis is a condition in which tuberculosis has spread to the whole of the body.

Normally it takes several days to weeks or even months for the tuberculosis to spread for one organ to the entire body of the patient.  However, in this case the tuberculosis of the intestine had got burst in a day or two and if this happens, the condition of the patient may deteriorate suddenly due to release and spread of fecal matter.  The mortality rate is very high who present themselves with such conditions.

Observations: Exploratory laparotomy was the right procedure to be performed on her, it was not necessary to subject the patient to a MRI Scan and / or CT Scan before undertaking the said procedure.  Witness clearly stated that it is the clinical finding in combination with blood reports that may suggest the diagnosis of acute abdomen requiring exploratory laparotomy and it is not always necessary to get any investigations done before undertaking this procedure.  Therefore, it was not necessary for opposite party No.2 to subject the patient to further investigation before undertaking the exploratory laparotomy on her. Patient had already been subject to ultrasound test at Suvidha Diagnostic Centre and a Heterogenous l mass of 60×47 cm had already been detected in her Adnexa region. As per directions, the opposite parties filed affidavits of Dr. Ajay Bedi and Dr. Nidhi stating that well-equipped 3-Bedded operational ICU was available in Mahesh Hospital on 28.6.2012, which they had submitted to the Government of NCT of Delhi and ICU rates have been clearly notified in the aforesaid Schedule of charges with effect from 01.1.2010.  It cannot be said that the procedure was performed in a hospital without having ICU facility.
For the reasons stated hereinabove, I find no merit in the complaint, which is accordingly dismissed with no order as to costs.

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