Case Study

JUDICIAL VALUE OF EXPERT OPINION

Girishchandra v. Bhatt   v. Sterling Hospital, First Appeal No. 2491 Of 2017, Decided On 19 Mar 2018 by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi


Facts: The complainants alleged that their son, Hitharth met with bike accident on 22-10-2013 at about 04:45 P.M., the truck run over Hitharth. Immediately he was admitted in Sterling Hospital (OP) at Rajkot. He was normal on admission with the exception of fractures. He was fully conscious for first two days without any major problems. All the reports were normal but thereafter his condition worsened and on 25-10-2010, he expired during treatment. Since the death of Hitharth had taken place solely due to negligence and carelessness in providing the treatment, the OP is solely responsible for the death of Hitharth.
Therefore, alleging case of medical negligence complaint was filed before the State Consumer Disputes Redressal Commission, Gujarat. On the basis of pleadings and arguments the State Commission dismissed the complaint at admission stage.

Grounds in Appeal: That Hitharth suffered multiple fracture injury on 22-10-2013 at Rajkot and he was admitted to Sterling Hospital for the treatment of simple fracture injuries. He was treated in ICU. For the first two days his condition seemed normal, he was talking with relatives, all the vitals and reports including CT scan was normal. However, from 24/25-10-2013 his condition started deteriorating. The OP failed to provide proper treatment. The haemoglobin level of the patient was going down which was not managed properly and further the lung infection was not controlled. Due to lethargic, negligent and sub-standard treatment from the OP, Mr. Hitharth passed away. His Post-Mortem (PM) report was stage managed by the OP. It was stated that the cause of death as “cardio respiratory failure due to poly trauma and its complications”. It was a simple fracture which could not resulted into the death of the patient. Therefore, it was negligence on the part of the OP. State Commission has totally ignored Expert opinion and dismissed the complaint without giving any findings on the Expert opinion; thus, it was against the law, that there was no evidence to show the patient suffered DIC. The D-Diamer test showed abnormality which was indicative of fibrin degradation products. Thus, there were chances of clot formation and break down in the body. It was missed by OP. Even the OP did not care for low level of haemoglobin, albumin, etc.. The OP did not perform

investigation properly.

Observations: The main contention of counsel for the complainant is that Hitharth’s death was not due to injuries but he was died due to wrong treatment from the OP hospital. On admission to the hospital the record shows he suffered multiple fractures. The report of CT scan of abdomen with pelvis done on 23-10-2013 revealed following findings:
“Fracture of bilateral iliac bone posteriorly, left sacral ala, anterior column of right acetabulum, bilateral superior and inferior public rami and proximan sacral segment (2) on left side. Fracture is also seen involving lower sacral segment on right side with displaced fracture fragmen lies in presaeral region indenting posterior wall of rectum. Fracture is seen involving right transeverse process of L2 and L3 vertebra. No leak of contrast from distal colon is seen. No evident pneumoperitonium or significan peritoneal collection is seen except thin stripe of fluid in right parahepatic region.”

The x-rays showed that the patient had suffered fracture in the right Knee joint, bilateral superior and inferior Pubic rami. Also there was a fracture involving bilateral iliac posteriorly and left sacral ala, fracture of right lower margin of the sacrum with displaced fracture segment. The x-ray of Lumbo Sacral spine revealed fracture of right transverse process of L2-L3 vertebrae. As per USG abdomen and pelvis showed there was a clot and mild perivesical hematoma. Therefore, the gravity of injuries can be ascertained on the day of admission i.e. 22-10-2013. Thus, the submission of the appellants that only one fracture injury was there is unsustainable. The other laboratory reports like D-Diamer was 3 mcg/ml which is on higher side. Similarly, the CPK levels are 4741 units/ltr (normal 55 to 170). It clearly indicates there was deterioration of patient during course of treatment. On perusal of discharge summary it is clear that the patient was initially investigated and treated with higher antibiotics, the CT scan and X-ray reports also showed multiple fractures. I have perused the PM report also. The complainant alleged that there was a mischief done by the doctor who performed PM and the departmental inquiry had been initiated against him. In this context, I have perused the PM report. It showed haematoma in the chest wall but the size, extent of haematoma was not explained by the doctor who performed the PM. He has not mentioned correctly the fracture injuries on the body of the deceased. In my view there was no fault in recording the PM findings. On admission the OP hospital conducted series of x rays, pathology tests, sonography, CT scan of thorax and abdomen, LFT and immunoessays also. The USG abdomen and pelvis revealed clot and mild haematoma. It is pertinent to note that due to internal bleeding the OP managed the patient with transfusion by whole blood, blood components like Fresh Frozen Plasma (FFP), Red Blood Concentrate (RCC), Platelet Concentrate (PC), White Blood Concentrate (WBC), Platelet Aphaeresis (SDP). Thus, in my view the OP hospital took reasonable care, which was a standard of care during the emergency. During hospitalisation the patient was administered higher antibiotics also but despite all efforts the patient’s condition deteriorated and there was bleeding. The CPK and D-Diamer abnormal values clearly indicative of extensive muscle damage and DIC. Therefore, it was not the negligence on the part of the treating doctor.

On Expert Opinion: I have perused the Expert opinion which was given by Dr. Nitin Shah, an experienced surgeon qualified to be MS. On bare reading of entire Expert report in my view the Expert is trying to give his suggestions to the State Commission i.e. adjudicating body that, “admit the matter”. The relevant text from the Expert opinion is reproduced as below:
“I have been provided the medical file papers and consumer complaint copy relating to the death of Late Hitarth Bhatt. I have gone through the entire file, the consumer complaint and preliminary reply filed by the opponent. Based on this opinion and upon relying on the documents on record, the Hon’ble Commission may admit and eventually allow the complaint rightly filed for medical negligence of death of Late Mr. Bhatt. The matter may be admitted and finally be allowed in favour of the complainants due to the detailed opinion below. The Hon’ble Commission may entertain and allow the matter to ascertain as to what went wrong and what were the lapses. It seems that the skilled people did not act as per accepted medical norms. The skilled staff did not act promptly to handle such life threatening emergency condition which developed post admission to the hospital of a young promising boy.”

The expert also opined that the patient was given platelets and two bottles of blood which proves to be negligence on the part of the OPs. He also questioned about the mismatch blood transfusion or very fast transfusion. I am rather surprised that how the expert arrived to the conclusion of mismatching of the blood without any cogent evidence. The OP had transfused the blood after knowing the deteriorating haemoglobin level and the bleeding also. Similarly, he has commented on the infection as suspected hospital infection which is also a baseless submission. The expert in paragraphs 15 and 16 mentioned as below:
“15. The complainants have complained that they were not kept in loop during the treatment process. They were not allowed normal visiting hours in the ICU. This directly goes against the hospital policy and rights of the patients as enumerated by the opponent themselves.

16. It is also submitted by the complainants that the treating doctors in addition to treating the ICU patients had large number of patients in the OPD department. This shows that the treatment was done with negligence or minimal involvement of the main doctors under whom they had been admitted.”

According to the hospital policy and international ICU norms the visitors are not allowed randomly and the hospital shall prohibit multiple visitors to the ICU for protection of other patients also. Thus, the above observation is ridiculous one. The expert witness plays an essential role in determining medical negligence and the courts by and large rely on expert witness testimony to establish the standards of care germane to a medical negligence case. Generally, the purpose of expert witness is to describe standards of care relevant to a given case, identify any breaches in those standards, and if so noted, render an opinion as to whether those breaches are the most likely cause of injury. The expert witness is given more latitude. The expert witness is allowed to compare the applicable standards of care with the facts of the case and interpret whether the evidence indicates a deviation from the standards of care. The medical expert also provides an opinion (within a reasonable degree of medical certainty) as to whether that breach in care is the most likely cause of the patient’s injury. The expert opinion will not carry any value, if it is without the expert’s explanation of the range of acceptable treatment modalities within the standard of care and interpretation of medical facts. In my view the expert opinion in the instant case has failed to explain the elements of medical negligence. It is just a vague. It appears that, the expert is trying to favour the complainant and repeatedly making recommendation to the State Commission “To admit the complaint and decide in the interest of justice”; which is not a duty of an expert. Therefore, the expert opinion is not acceptable one as it has no evidentiary value.

Held: Considering the sequence of events and on perusal of the medical record it is clear that the deceased had suffered multiple fractures and was properly treated on emergency basis at OP hospital. The discharge summary clearly shows the details. The active bleeding and haematoma was treated by transfusion of blood and blood products as needed. The patient was monitored in the ICU during hospitalisation but unfortunately suffered respiratory arrest. The doctors immediately performed intubation and the patient was put on ventilator. The ionotropic drugs were also started but later on the patient suffered cardiac arrest at 09:30 P.M. and CPR was given as per ACLS protocol but the patient was dead by 10:16 P.M. It is settled law that the onus to prove medical negligence lies largely on the complainant and that this onus can be discharged by leading cogent evidence. A mere averment in a complaint by no stretch of imagination, be said to be evidence by which the case of the complainant can be said to be proved. It is the obligation of the complainant to provide the facta probanda as well as the facta probantia. In my view the present the Consumer Complaint completely lacks facta probantia and ought to be dismissed on that ground alone. On the basis of foregoing discussion I do not find any illegality or perversity in the well-reasoned order of the State Commission. Hence, the appeal is hereby dismissed in limine.

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