Case Study

New act intervening, ‘novus actus interveniens’

Dr. Samir Rai & Anr. v. Medanta Hospital & Ors.
Decided on 11 August, 2020 by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi

FACTS: Complainant was diagnosed to have Aneurysm of the arch of Aorta and on 11.07.2010. On 12.07.2010 he got admitted in Medanta Hospital for replacement of Aortic arch, the CT scan and other investigations were performed on 16.07.2010. It was alleged that the CT contrast material   caused severe reaction and resulted into hoarseness of voice and bout of blood came from throat, that the diagnosis of rupture of the Aneurysm was totally wrong, and the OPs decided to perform urgent surgery on the next day, that the doctors did not provide proper information about the nature of disease and choice of surgery to be performed, that the consent was not an informed consent, as both the Complainants were surgeons and would have preferred the endoscopic (closed) method of surgery as it was suggested by one Cardiac surgeon Dr. Rakesh Sudan, but the doctors performed open surgery, that due to unhygienic conditions in the operation theatre the two surgical wounds (one in the groin and one on the chest) became infected and started oozing pus, that for its treatment the doctors advised further operations on both the sites, but the patient did not agree and he protested that it was against the established surgical principles. For the infected surgical wound in the right groin, OP-3 planned the debridement and secondary suturing on 5.8.2010. At 11-30 a.m., the patient was seen by Dr. Shivani, respiratory specialist and advised if possible General Anaesthesia (GA) should be avoided, as the patient was at high risk. The advice was ignored by the treating doctors and asked the patient to sign Consent form for surgery but the patient refused to sign the Consent form. However, the surgery was forcibly done under GA. The patient came out of anaesthesia and he had severe pain in his right thigh and his whole right arm became numb (paralysed), that after four days, OP-3 performed another operation for the wound on chest at the lower end of sternum, that it was done under intravenous sedation and not under GA, that Consent form for the said surgery did not bear the signature of the patient but it merely carried patient’s thumb impression, that the thumb impression was attested by Dr. Saxena on behalf of the OPs. At the first time Dr. Sumit Singh noted the paralysis of patient’s right hand on 10.8.2010 and advised for physiotherapy & re-evaluation; but nothing was done. The patient was discharged from OP-1 hospital on 16.08.2010; the discharge summary was surprisingly silent about the paralysis of right hand, the patient suffered during treatment. Again on 19.08.2010 the patient was readmitted to the hospital. Again, the admission record and the clinical findings were silent about the paralysis and it was recorded as ‘NONE’ for the neurological and musculo-skeletal system, that the patient was discharged from OP hospital on 25.08.2010. Thereafter, during next 3½ years the patient underwent 19 surgeries at Amritsar by the surgeon Dr. Jasdeep Singh for healing of both the wounds [Incision and drainage (I & D)], that the groin wound eventually healed in mid-November, 2010, but the chest wound remained un-healed till the death of the patient.  It was alleged that the patient died due to the complications of non-healing chest wound which was caused due to the negligence during surgery.

DEFENCE: Patient was referred from Amritsar for the treatment of infected mycotic Aneurysm of arch of Aorta, on admission (12.07.2010) patient was presented with ruptured Aneurysm and he was in a highly toxic state, around 95-100% risk to life, the patient was treated at OP-1 hospital as per medical standards, the patient survived for almost 3 years after treatment. The patient during Psychiatric consultation, himself admitted that for the past 5-6 years he was a habitual user of drug Pentazocine and Midzolam.On 16.7.2010 patient developed severe back pain, acute hoarseness of voice and fresh haemoptysis (blood in sputum), it was an indication of rupture of Aneurysm with Recurrent Laryngeal nerve (RLN) involvement. Based on the condition of the patient, since the Aortic aneurysm had ruptured, the ‘Endo-Vascular’ and/or ‘Hybrid’ procedure were not possible. The only option available to perform surgery was by “Open Procedure”.  After taking patient’s informed Consent, on 17.07.2010, doctors performed surgery under Deep Hypothermic Circulatory Arrest (“DHCA”) and replaced the infected Aneurysmal Arch with ‘24 mm Dacron branched Arch Graft’.  For the proper perfusion of the body most common access through the groin vessels was used during the operative procedure. The right Femoral artery was exposed through vertical incision and it was sutured after surgery.    On 03.08.2010, OP-3 examined the groin wound and planned for removal the slough below the femoral bed. Accordingly on 05.08.2010 after taking High Risk Informed Consent the OP-3 performed debridement of the groin wound under GA. The patient was kept under observation. He did not complain of any weakness in right upper limb. On 09.08.2010, the patient developed soakage and gaping of chest wound at the lower end of sternum, therefore secondary suturing to close the wound was done, on the same day under local anaesthesia the informed consent was given by patient’s wife. The Neurology team examined the patient on 10.08.2010 and found the patient’s right shoulder movement was near to normal, mild weakness in elbow and hand function (grip) was poor. It was suggestive of involvement of lower trunk of Brachial plexus, but it was not due to the debridement surgery, as it was done on supine position which has no chance of Brachial plexus injury. According to OPs the weakness of the right upper limb was possibly due to secondary effects of self-injecting drugs Pentozocine and Midzolam into his arms.     The patient was discharged on 16.08.2010 without any signs of paralysis of the right upper limb. He was advised physiotherapy and follow-up.  On 19.08.2010, the patient came once again to the Hospital with the complaint of breathlessness, and he was stabilised. On 23.08.2010, the Neurologist examined the patient and found improvement in the right Brachial prexopathy. Patient was discharged on 25.08.2010, thereafter he never turned up to OP-1 hospital. Thus  No negligence occurred during the entire treatment. The patient survived for 3 years after discharge.

FINDINGS: Prior to surgery the patient was properly investigated at the Hospital. The CT-Angio, ECHO, Carotid Doppler & Peripheral Doppler studies were done. The clearance for surgery was taken from consultants of various departments like Internal medicine, chest physician, Gastroenterology, Nephrology and Endocrinology. On 17.07.2010 the doctors performed surgery and replaced the infected Aneurysmal Arch with ‘24 mm Dacron branched Arch Graft’ under Deep Hypothermic Circulatory Arrest (“DHCA”).  The medical literature revealed three types of surgical approach as one available for treatment of mycotic Aneurysm of aortic Arch viz. (i) Open Procedure, (ii) Endo-Vascular Procedure and (iii) Hybrid Procedure.  It is pertinent to note that the patient was already in immuno-compromised state and to operate the leaking infected Aneurysm of Arch of Aorta, the Endo-Vascular procedure was not suitable. Thus, doctors chose the “Open Procedure”. Moreover, the Hybrid Procedure is still in evolving stage, not approved by FDA. Thus, the allegation of complaint for not choosing Endovascular procedure is devoid of merit.  The patient had morbid obesity with a low tolerance to pain. The groin wound debridement surgery was necessary for removal of slough/dead tissue lying around the sutured Femoral artery. To minimize the risk of damage to the Femoral artery O.P. doctor decided to perform the surgery under General Anesthesia and the local anesthesia is not more effective in the presence of any infection. The OP doctor performed debridement of wound after obtaining valid consent. Consent forms dated 04.08.2010, 05.08.2010, 09.08.2010, have been signed by the Complainant No. 2, the wife of the patient for pleural tap, groin wound debridement and chest wound closure respectively. Treatment given at OP-1 Hospital was per reasonable standard procedure with due informed consent.

HELD: After discharge from OP-1 Hospital on 25.08.2010, the patient never visited OP-1 Hospital. He took further treatment at Amritsar and underwent 19 surgeries. Therefore, the principle of Novus Actus Interveniens demolishes the entire case of complainant. The term ‘novus actus interveniens’ (“new act intervening”) is a legal term which refers to breaking the chain of causation such that even if the defendant has acted negligently, a subsequent intervening action breaks the chain of causation with the loss or damage sustained and so the defendant is not liable. The facts and specificities of the present case, in our considered view, the Complainants, though being well qualified doctors, concealed that the Complainant No.1 was addicted to drugs. At the OP-1 Hospital, the treating doctors investigated and treated the patient as per the standard medical practice. We do not find deficiency / negligence in conducting the surgery for replacement of the infected Aneurysm of arch of Aorta with ‘24 mm Dacron branched Arch Graft’ or in the post-operative wound care and follow-up. Admittedly, the patient died three years after the Arch replacement, there appears no nexus between the surgical treatment and the death of the patient after 3 years.    In the light of the above discussion, deficiency / negligence cannot be conclusively established on the treating doctors / hospital. The Complaint is dismissed.

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Anoop K. Kaushal

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