1. THE father, widow and mother of the deceased Rajesh Bhandari, complainants Nos. 1 to 3, have filed a complaint for recovery of Rs. 10 lacs
on account of compensation and Rs. 4,481/- as cost of medicines against Sir Ganga Ram Hospital and Dr. T. Singh, a consultant, defendant Nos.
1 & 2. THE case of the complainants is that Rajesh Bhandari fell ill in the morning of 21st May, 1989. On the next day he was got admitted to
Kapoor Hospital. THE complainants were informed by them on 22nd May, 1989, that he was suffering from a serious ailment and therefore, he
should be removed to some other hospital. THEy brought him in a serious condition to the emergency unit of Sir Ganga Ram Hospital, (hereinafter
referred to as the Hospital) at 11 p.m. on the same day for treatment. He was admitted there and was examined by Dr. T. Singh, consulting
surgeon on 23rd May, 1989. After a preliminary examination, Dr. T. Singh and a team of doctors of his unit disposed that it was a case of
pancreatitis, a dangerous disease.
2. IT is alleged that inspite of his serious condition and dangerous type of disease he was admitted to an ordinary room instead of Intensive Care
Unit (ICU). IT is further averred that immediate scan of his abdomen was necessary to confirm the diagnosis of the disease but that was got done
on 24th May, 89 at 11.30 a.m., i.e. after 36 hours of his having been admitted to the hospital. The scan showed that because of 36 hours delay,
the galloping disease had reduced the pancreas to a slough and the toxins were spreading rapidly in the patient''s system.
It is next pleaded that the operation was the only way to save the life of the patient but defendant No. 2 and his colleagues delayed the operation
on account of their negligence. Thereafter the patient started vomiting blood and passed into coma but still defendant No. 2 went on administering
oral medicines though they had no effect on the patient. Even then the said defendant did not operate upon him to save his life which showed gross
negligence on his part,
In the evening of May, 24,1989 Dr. T. Singh informed them that the condition of the patient was very serious and they should pray for his life. It is
stated that despite the seriousness of the disease of the patient he was not removed to ICU. On the contrary he was left to the care of nurses and
junior doctors on the night duty. Defendant No. 2 even did not make any arrangements to monitor the condition of the patient in his room in the
private ward though his condition during the night of May 24, 1989 was very critical. On the morning of 25th May, 89 the condition of the patient
deteriorated .beyond redemption. Defendant No. 2 came in the morning to examine the patient. After a short time the patient was declared as
dead.
3. IT is also alleged that the patient was feeling difficulty in breathing due to spreading of toxins in the body. The difficulty in breathing increased
further during the night of 24th May, 1989, but he was not even provided respirator by the defendants. That further shows negligence on the part
of the defendants.
The complaint has been contested by both the defendants. Defendant No. 1 in the written statement admitted that the patient was admitted to the
hospital on the night of 22nd May, 89. It, however, pleaded that as per terms of the agreement between the defendants, defendant No. 2, a
consultant, like other consultants was not an employee of the hospital and did not receive any remuneration from it. He charged his fees from the
patients according to the treatment given to them. The hospital provided supportive services like room, diet, nursing etc. The patient was admitted
through casualty unit of the hospital by his wife in surgical unit No. 1 which was headed by defendant No. 2, whose unit was on emergency on that
day. At the time of admission he was examined by Dr. Minocha, M.S., Dr. R. Sarangi, M.S., Associate consultants of the unit and later by Dr. T.
Singh, and it was diagnosed that he was suffering from acute pencreatitis. No bed was available in ICU throughout the stay of the patient in the
hospital, but it did not make any difference if the bed in ICU was not available, as all the treatments could be given to the patient in his ward.
4. IT is alleged, that the patient was put on vigorous treatment by the doctors consisting of defendant No. 2, Senior consultant surgeon, Dr. P.S.
Gupta, Sr. Consultant Physician, Dr. R. Sarangi, Associate Consultant Surgeon, Dr. S.P. Byotre, M.D. consultant physican and number of other
doctors. The patient remained in the hospital for a period of 57 hours and during that period the doctors visited him round the clock and keeping in
view the condition of the patient all the tests were conducted. However, the disease of the patient progressed very rapidly and the same took the
fulminant course. All along the treatment of the disease was carefully planned but the operation was not performed on account of a wellconsidered
and deliberate decision, based on the present day accepted medical opinion as well as experience. There was no negligence on the part of
defendant No. 2 or the hospital.
Defendant No. 2 in his written statement took similar pleas as were taken by defendant No. 1. He further stated that the patient was in a serious
condition when he was admitted to the hospital. The surgical unit was under the joint charge of defendant No. 2 and Dr. R. Sarangi. Dr. R. Sarangi
examined the patient immediately after admission and he continued to monitor patient''s progress throughout. He i.e. Dr. T. Singh examined the
patient for the first time in the morning at 11.00 hours on 23rd May, 89. No bed in ICU was available in the hospital throughout the patient''s stay
in the hospital. Despite that intensive monitoring/treatment of the patient was done in the patient''s room. It is alleged that during his stay more than
140 visits by the paramedical staff besides 25 visits by various consultants for monitoring/treatment were made.
It is next averred that the prognosis was grave and that matter had been explained to the friends and relations of the patient including the
complainants. The C.T. Scan was not done on the 1st day as the condition of the patient was not stabilised and it was not possible to remove him
to the C.T. Scan room. Moreover, the patient was not in a condition to stand 40 minutes test of C.T. Scan of adbomen on that day.
5. THE first contention of Mr. Bhandari, the complainant, is that the deceased was not admitted to ICU, which taking into consideration the nature
of the disease, was very essential. In case no bed was available in the ICU, he should have been informed about it so that he could have made
arrangement in some other hospital. On the other hand the learned Counsel for the respondent has vehemently argued that no bed in ICU was
available but all the facilities which were available in the ICU, had been provided to the deceased in the private room and thus it did not make any
difference, whether he was in a private ward or in the ICU.
6. WE have heard the complainant and the Counsel for the respondents at a considerable length. The first question that arises for determination is
whether it was essential that the patient should have been transferred to ICU for treatment of the disease. The patient was brought to emergency
ward of the hospital before 12.00 midnight on 22nd May''89 and admitted there at 00.15 hrs, on 23rd May ''89. He was allotted room No. 313 in
private ward. Dr. Minocha, Consultant attended on the patient according to the admission notification slip, he put him under Dr. T. Singh''s team.
Further Dr. Minocha prescribed that he should be transferred to ICU urgently. From the said note, it is evident that the consultant at the time of
admission of the patient was of the view that he should at once be provided bed in ICU. At 2 p.m., the history sheet shows, the patient was in bad
condition and the doctor who attended on him, advised to get some one for consultation from ICU and also to contact Dr. T. Singh. Dr. T. Singh
came at 2.25 p.m. and he after examining the patient made the following note : - ""Please transfer to ICU as soon as bed is available. Booking has
already done as noted on admission slip.
Dr. Samir Kapoor on 24th May ''89 examined the patient at 5 p.m. and he also said that the patient be transferred to ICU. Dr. P.S. Gupta, Sr.
Physician came to the patient on the same date between 5.10 pm and 5.20 pm. He also prescribed that the patient be transferred to ICU. At this
stage I shall refer to a para from a treatise, titled as Gastrointestinal Disease Pathology Diagnoses Management by Marwin H. Sleisenger, M.D.
and John S. Ferdtran, M.D,. 3rd Edition Vol. II. the relevant head note is Necrotizing and Prolonged Pencreatitis (page 1478). It is observed,
under sub-head ""Criteria of Severity''.
The patient with necrotizing pancreatitis requires close monitoring of central venous pressure, urine output, blood gases, body weight and
temperature. Serial laboratory Determinations should include serum bilirubin and calcium, blood glucose, and hematocrit. Laparectomy is indicated
when the diagnosis remains in doubt and when acute cholecystis or common duct stone impaction with or without acute cholengitis is suspected.
This matter has also been discussed in Malugots Abdominal Operations Edited by Seymour J. Schwartz and Harold, Ellis (eighth edition) at page
2040 in a slightly different form. The relevant portion reads as follows :-
Respiratory Monitoring and Support Since early respiratory failure occurs in patients who do not have severe disease by the usual clinical criteria
and who may not have any obvious clinical evidence of pulmonary insufficiency, it is essential that artorial blood gas values to be determined at
diagnosis and at intervals of not less then 12 hours for the initial 48 to 72 hours of treatment in every patient. In most patients with early are material
the only necessary management is alone monitoring and administration of oxygen. Inpatients with progressive respiratory failure the volume of fluid
administered intravenously should be decreased and the urinary output maintained on increased by the administration of diuretic drugs. There is
usually no clinical or retrographic evidence of fluid overload in these patients, but improvement of respiratory function is often observed following
such management. In those patients with severe pulmonary insufficiency, endotracheal intubation and positive-end-expiratory pressure ventilation
should be instituted early.
7. THE above quotation also deals with respiratory monitoring and support. It is therefore, proper to deal with this aspect of the matter herein. Dr.
Sarangi and Dr. Minocha in this regard made the following remarks at page-5 of the history-sheet.
Pallor Dyspnosic, No icterus, cyanosis, edern RS. (Respiratory System) Lungs clear CVS (Cardiovascular System) SI S2+
Dr. R. Sarangi on 23rd May''89 at 4.10 A.M. says as follows : -
Severe dyspnoes, with Wheeze Tenderness not significant. Imp. (impression) ARDS (Acute respiratory distress syndrome)."" Dr. T. Singh in his
note dated 23rd May''89 (11 A.M.) says ""Yesterday at about 11 A.M. he developed breathing difficulty which is persisting. Patient is not passing
gas per rectum. Complains of adbominal distension.
The following note appears in history sheet dated 24th May''89 (5 pm) ""OE patient gasping"". OE means, on examination. Again Dr. Samir Kapoor
examined the patient at the same time and prescribed that the patient be transferred to ICU. He also prescribed oxygen (O2) by nasal catheter. On
the same day at 8.30 P.M Dr. R.N. Jain found that the patient was gasping. Again on the same day at 10.30 P.M and 11.30 P.M and on 25th
May, 89 at 2 AM and 8.15 A.M. history sheet shows that the deceased was gasping.
8. FROM the above said reports it is evident that the doctors including Dr. T. Singh were of the confirmed view that the patient should be
transferred to ICU. We think they were right in saying so. The deteriorating condition of the patient required close monitoring and that was
possible in ICU and not in the room. In the ICU the doctors and the nurses not only stay within the sight of the patients but they keep close watch
on them. This facility was not possible in the private ward. All the necessary equipments are always available in the ICU. That is why the attending
doctors always said that the patient should be removed to ICU. However, plea has been raised on behalf of the hospital and Dr. T. Singh that all
facilities of ICU had been provided in the room of the patient and therefore it did not make any difference whether he was being treated in a
private ward or in ICU. This plea does not appear to be correct and is an after thought. It is also alleged that ICU facilities were made available to
the patient shortly after his admission to the hospital. If it was so why on 23rd May''89 Dr. T. Singh at 2.25 P.M himself prescribed ICU for the
patient and thereafter till the evening of 24.5.1989 various doctors had been prescribing that the patient be removed to ICU.
It cannot be disputed that in ICU there are more facilities for monitoring the disease. It is not established that the facility of doctors and nurses was
provided to the patient in the same way as it would have been available to him in the ICU. It has also not been proved that instruments were
provided to the patient in the room. A contention has been raised that the doctors and the nurses could be called at any time by the relatives of the
patient. This contention is without any merit. The patient was in a very bad etato of affairs and it was not possible for the relations to run after the
doctors and nurses all the time. In Wards, the doctor and nurses on duty have to take care of a large number of patients, where as the position is
quite different in ICU.
Mr. Bhandari has also submitted that some interpolations were made in the record after the complaint had been filed by him, and that is why the
record was not produced by the authorities alongwith the written statement. It is true that the defendants should have produced the record of the
hospital along with the written statement so that there could be no possibility of interpolating the same. However, the complainant was unable to pin
point which of the entries had been interpolated by the defendants subsequently. Mere suspicious that the record might have been interpolated
cannot take the place of proof. In this situation it cannot be held that there was any interpolation in the record of the hospital.
9. AFTER taking into consideration all the aforesaid circumstances I am of the view that it was essential that the patient should have been
transferred to ICU for treatment of the disease.
10. THE next question that arises for determination is whether any bed in ICU became available during the period the patient remained in the
hospital. THE defendants, in their written statement stated that the bed was available in the ICU during the stay of the deceased in the hospital. It is
not disputed that there were 20 beds in the ICU of the hospital. It is alleged that out of them 10 beds were reserved for the general patients and 10
for heart patients. THE deceased, according to them, fell within the former category. However, to support their contention no record has been
produced. If some rules have been framed by the hospital for demarcation the ICU beds for different type of patients, it was their duty to have
produced the same. In the absence of the record the version of the hospital cannot be accepted. Assming for the sake of arguments that such a rule
had been framed by the authorities concerned, was it such an imperative rule, that in the case of emergency it could not be violated. THE deceased
remained in the hospital for 57 hours. THE version of the defendants that no bed became available during these 57 hours, is difficult to believe. It
was the duty of the defendants to produce the record of the hospital to prove that no bed in ICU became available during the stay of the deceased
in the hospital. Defendant No. 1 for the reasons best known to it did not produce the record. Dr. T. Singh also failed to get the same produced. In
this situation an adverse inference has to be drawn against the defendants.
The matter may be examined from another angle. It was the duty of the doctor-incharge to find out, whether any bed could or could not be made
available in the ICU shortly after admission of the patient in the hospital. If he was of the opinion that it was not possible to provide a bed in ICU to
the deceased it became the duty of the doctor in-charge and hospital to have informed his attendants in that regard. It was also the duty of Dr. T.
Singh and the Members of his team to find out from the in-charge of ICU as to when the bed would be available. There is nothing on the record
that defendant No. 2 or any of his assistants made any enquiry regarding the said facts. The patient, as already mentioned, was admitted to
Kapoor Hospital before his admission to Sir Ganga Ram Hospital and the authorities of the former hospital had informed the complainants that the
patient be removed to some other hospital as they were not in a position to treat him. That is how the patient has brought to this hospital. If
defendant No. 2 or the hospital had informed the complainants that they were unable to provide accommodation to the patient in ICU, then it
would have been the duty of the complainants to decide whether the patient was to be kept there or was to be transferred to some other hospital.
An agreement was raised on behalf of defendant No. 2 that it was the duty of the hospital to provide a bed in the ICU to the deceased and if they
failed to do so, defendant No. 2 cannot be held responsible for that.
11. THE arguments on the face of it appeared to be very attractive but when examined in some depth it was found without merit. No doubt it is
true that the bed was to be provided in the ICU by the hospital authorities but it also became the duty of D T. Singh and his team to pursue this
matter vigorously with the hospital authorities and persuade them to give him accommodation in ICU. If still the hospital could not provide the bed
in the ICU, it was his duty to have informed the complainants that it was not possible for the hospital to provide accommodation there. I have very
carefully seen the history sheets of the hospital produced on the record and find that there is nothing in them to show that defendant No. 2 or any
member of his team persuade the matter with the hospital authorities. It was also expected that note in that regard should have been given on the
history sheet that no bed was available in the ICU and it was not possible to provide one within the next 2-3 days.
Now it is to be seen whether this commission amount to negligence on the part of the defendants. It is well settled that while treating a patient, a
medical person in addition to using reasonable degree of skill and knowledge must exercise a reasonable degree of care. He owes a duty to the
patient to use diligence and care. If he fails to do so, he becomes guilty of negligence and makes himself liable to pay damages. What is reasonable
degree of care, that varies in each case and no hard and fast rule can be laid down to find out the same. However, a medical person cannot be
held negligent simply because something happens wrong to the patient. He can be held guilty of negligence, when he falls short of the standard of a
reasonably skilful medical person in his field.
12. AFTER taking into consideration all the circumstances, I am of the view that negligence on the part of the defendants is established as they
failed to inform the complainants that it was not possible for them to allot a bed in the ICU, within a short period after his admission. In case he had
been admitted to ICU it was possible that his end would not have come so early. However, it cannot be forgotton, that pancreatitis is a deadly
disease and the stage at which the disease had reached, it might not have been possible to prolong the life of Rajesh for a long time. Even if the
duration of his life could be extended for a short time that would have given great relief to the complainants and other relations. It cannot be
doubted that the complainants have suffered great mental distress and agony on the death of Rajesh. Consequently, I grant exemplary damages to
the complainant, which I assess at rupees one lakh. The hospital was mainly responsible for not informing the complainants that no room could be
made available for the deceased. Therefore, in my view, the hospital is liable to pay Rs. 80,000/- and Dr. T. Singh is liable to pay Rs. 20,000/- as
damages to the complainants.
It has next been argued by Mr. Bhandari that the deceased was gasping and it was essential that he should have been provided with a respirator,
but it was not done. It is submitted that it is an act of negligence of the highest degree on the part of the defendants. I have duly considered the
matter. It is true that it was found by the doctors attending on the patient that he had been gasping for a long time. The reports of the doctors
attending on him have been reproduced above. However, the patient was being given cent percent oxygen and in that circumstance, according to
the respondents, it was not necessary that the respirator should have been provided to him. In reply to the interrogatories, Dr. T. Singh said,
....The team of doctors, specially consultants, anaesthetist, Dr. Subhash Gupta and senior consultant physician Dr. P.S. Gupta, did not summoned
use of respirator. The judgment of 5 doctors at 5 pm on 24th May, 1989 for non-use of respirator was unanimous."" It is well-settled that in order
to prove the negligence on the part of a doctor it is for the patient or his legal heirs in case of his death, to do so. No evidence has been brought on
the record by the complainants that the statement of Doctor Singh is incorrect and that providing cent percent oxygen to the patient was not
sufficient. Even no reference from some well-known treatise on the subject was made by them which supported the contention of the complainants.
Therefore, I do not find any merits in the contention of Mr. Bhandari and reject the same.
It has next been argued by Mr. Bhandari that the scanning of the patient was done after 36 hours of his admission into the hospital whereas it
should have been done immediately so that the diagnosis of the disease could be finally confirmed. He submits that it was culpable negligence on
the part of Dr. T. Singh and his team not to get the scanning of the patient done immediately. On the other hand Mr. Parikh has submitted that the
disease had taken a very grave course and it was not possible on 23rd May''89 to get the scanning done, as the patient could not stand strain of
the scanning. According to him as soon as the patient improved a little and became fit for scanning it was got done.
13. WE have duly considered the arguments of the learned Counsel. It is also not disputed even by the complainant that the patient was very
seriously ill. Dr. T. Singh has stated in the written statement, which is supported by an affidavit that in the case of acute pancreatitis, pancreatic
secretions went into the food passage. When pancreas got acutely inflamed, these secretions got spilled through inflamed gland tissue into the
surrounding areas and started the process of autodigestion of the structures on the back wall of the abdominal cavity. The process of autodigestion
did not respect any boundaries and when the outpouring was massive, these went into the chest and behind the lungs. The disease in the case of
deceased was so severe that fluid had collected on both sides of chest cavity in addition to abdomen. It was like a ""house on fire"" and in 10% of
the cases the disease progressed relentlessly and took a fulminant course. The severity and graveness of the disease was akin to very massive heart
attack. In the written statement of defendant No. 1 it was pleaded that on 23rd May''89 C.T. Scan was advised by Dr. P.S. Gupta but the patient
was in bad condition and as such C.T. Scan was not got done. In the afternoon of 23rd May''89 the condition of the patient became worse and
the vigorous treatment continued. It is further stated that on 24th May''89 Dr. T. Singh examined him and found improvement in his condition and
as such advised C.T. Scan which was got done thereafter. Dr. T. Singh in his written statement at page-34 stated that the C.T. Scan was taken
only when the patient was considered to be fit enough to be sent to the Scan Centre. The patient had to be subjected to a forty minutes test of
C.T. Scan of abdomen. The patient was not in a condition to stand 40 minutes test scan on the first day. It was got done only when it was
considered safe. He further stated that the purpose of C.T. Scan was to confirm diagnosis and the extent of the disease and to find out the
presence of any complication. In the present case it had been dignosed that the patient was suffering from pancreatitis and that there was no
complication like necrosis, abscess formation of any cyst. There are no grounds to disbelive the affidavit of Dr. T. Singh. His statement finds
support from ''Pancreatitis'' Edited by David D. Carter and Andrew L. Warshaw 1989 Edition. In the preface of the book it is said by the Editors
as follows : -
Diseases of the pancreas continue to constitute a major challenge despite recent advances in methods of diagnosis. In this volume we have
selected to concentrate on the problems posed by acute and chronic pancreatic inflammation. Acute pancreatitis remains a common cause of
significant morbidity and mortality, while the less common chronic pancreatitis poses major challenges in the treatment of intractable pain against a
background of impaired pancreatic endocrine and oxocrine function. WE have been fortunate in having recruited a team of internationally
recognised contributors, each of whom is an authority in his chosen field. WE trust that this volume will be of value of those concerned with the
management of patients with acute and chronic pancreatitis, and that it will provide a useful review of some of the more controversial areas of this
evolving sector of surgical endeavour.
Edinburgh and Boston 1989 D.C.C A.L.W"" The authors deal with C.T. Scan as follows : -
(iii) Computerized tomography CT Scanning can be performed with contrast medium instilled into neighbouring organs such as gallbladder,
stomach, duodenum, and colon, but this is seldom feasible in the acute phase, that is in the first week after the onset of the disease valuable results
are not obtained at this stage. This examination is helpful only after the acute symptoms have subsided and should be used if ultrasonography fails
to provide enough information.
14. THE above said quotation fully fortifies view expressed by Dr. T. Singh. Mr. Bhandari served interrogatories on Dr. T. Singh. In answer to a
question regarding scanning Dr. T. Singh states that if C.T. Scan had been done on 23rd May ''89, that would not have altered the course of
disease or the line of treatment. It is not disputed that C.T. Scan was not a treatment. It was got to be done for the purpose of diagnosis, which
had been done. In case the patient was not in a position to stand for C.T. Scan, no useful purpose would have been served by doing C.T. Scan.
THE treatment of Dr. T. Singh who is a well known surgeon, that the patient was not in a position to stand the C.T. Scan on 23rd May ''89 can
not be brushed aside. No evidence worth the name has been laid on behalf of the complainant contradicting the stand of Dr. T. Singh.
Consequently I do not find any merit in the contention of Mr. Bhandari and reject the same.
The next contention of Mr. Bhandari was that it was necessary to perform the operation immediately as there was progressive clinical deterioration
in the condition of the patient. If operation was not advisable, in order to save the life of the patient at least peritoneal lavage should have been
done. He further submitted that the Pancreats of the patient should have been removed so that his life could have been saved. On the other hand
the learned Counsel for the respondent urged that it was not possible to operate upon the patient when the disease had taken fulminant course. He
to support his version referred to the W.S/Affidavit of Dr. T. Singh and the various treatises containing the opinion of eminent doctors.
It is stated by Dr. T. Singh in answer to the interrogatories that operation could not be performed on the patient in that severe condition. He is a
well known surgeon and a Senior Consultant in Sir Ganga Ram Hospital. He is Honorary Consultant to Armed Forces Medical Services (Indian
Army, Navy and Air Force), Ex. Hony. Surgeon to the President of India, Ex. Professor of Surgery, (Armed Forces Medical College, Pune.),
Member of the Board of Speciality, National Board of Examinations, Examiner in surgery for the degrees of MBBS, MS and National Board of
Examinations for Diplomate Surgery. All the aforesaid qualifications show that he was competent enought to deal with the disease. His view that
the patient should not have been operated at that stage finds support from the various eminent authors. Before referring to the books it is relevant
to find out what pancreatitis is and how the disease affects the human body. Dr. T. Singh in the written statement has defined the disease in the
following terms :
15. PANCREAS is an elongated gland lying transversely in the back of abdominal cavity above the level of navel, PANCREAS produces :
(a) Secretions rich in enzymes, which digest proteins, fats and carbohydrats in the food. These secretions are poured directly into the part of the
food canal called duodenum. One of the constituent enzymes called amylase is so powerful that if put in test tube containing a piece of meat, the
meat will dissolve rapidly. When poured into the food passage naturally they are the best friends of the body, because they help in assimilation and
digestion of food. If these enzymes spill outside anywhere in the body, they indiscriminately start autodigesting the body. In acute pancreatitis when
the pancreas get inflammed, large amount of outpouring of enzymes not only starts the process of autodigestion, but the enzyme gets absorbed in
blood. The level of this enzyme is an important criteria of diagnosis of the disease amongst others. (b) Harmones like Insulin, is required for
utilisation of glucose by the body. In pancreatitis when the gland is inflamed, the insulin production by the gland is reduced producing a rise in the
level of blood sugar. This was so in case of the patient (c) Lipase, digests fats. In pancreatitis, spillage of this enzymes, starts digesting fats, which
attract calcium in the body to form insoluble salts. Thus the level of serum calcium falls (d) What happens in acute pancreatitis? Pancreatic
secretions normally go into the food passage. When pancreas gets acutely inflamed, these secretions get spilled through inflamed gland tissue into
the surrounding areas and start the process of autodigestion of the structures on the back wall of the abdominal cavity. This process of
autodigestion does not respect any boundaries, and when the outpouring is massive, even go into the chest, and behind the lungs....
When there is massive and indiscriminate destruction of the body tissues by autodigestion, it not only liberates some very powerful toxic enzymes,
but also the body fluids start pouring into the area, as a nature''s effort to dilute the process. This causes shift of fluids inside the body and cause
dehydration. It can be severe enough to kill the patient by itself.
In the present case, most of the tests of the patients had been done after his admission to the hospital. The tests showed that the level of amylase in
blood had risen to 2190 units against the norm of 10-220 units. The level of serum calcium had fallen to a dangerous level of 5.9 meq/litre against
norm of 8.1 to 10.4 meq/litre (meq - milieguivalents), (page 7 of written statement of Dr. Singh). The pancreatic secretions normally go into the
food passage but when pancreas get actually inflamed, the secretions get spilled into the surrounding areas and start autodigestion of the structures
on the back wall of the abdominal cavity. In the case of the patient, the fluid had collected on both sides of the chest cavity in addition to abdomen.
There was dehydration in the patient and he had been given 15 bottles of fluids intravenously. It is thus evident that the disease of the deceased had
taken a very grave course. This fact is even admitted by Mr. Bhandari.
16. NOW reference may be made to various books which were cited at the bar. In the ''Pancreatitis'' (supra) it is stated at page 36 as follows : -
Ranson et.al. found that in patients with objective evidence of severe acute pancreatitis there was a mortality rate of 16% for conservating
management and 67% for those undergoing early laparotomy (Ranson et al 1976). Earlier prospective studies by our team in Glasgow, without
distinguishing between severe and milder forms of pancreatitis, have shown a similar increased incidence of complications and death in those
patients undergoing early surgery (Imrie & Whyte 1975). The most valuable study is one in which the New York University group found no
increased hazard in mild acute pancreatitis for limited operation (aspiration of fluid and placement of drains), but all forms of surgical intervention at
the early stage of severe acute pancreatitis added to the likelihood of death (Ranson 1984). In milder acute pancreatitis there is therefore little
additional risk from laparotomy early in the disease process, but the multisystem onslaught of severe acute pancreatitis is often exacerbated by
early surgery within 24-48 hours of hospital admission.
In the Year Book of Surgery Edited by Seymour I. Schwartz, 1989 Edition the Author was of the view that surging should be done after the
pancreatitis has subsided. The relevant observations are reproduced below : - ""Gallstone Pancreatitis : A Prospective Randomined Trial of the
Timing of Surgery. Kelly T.R. Wagner D.S (Northeastern Ohio Univ, Akron; Akron City Hasp) Surgery 104 : 600-605, October 1988 25-10
The correct timing of surgery for gallstone pancreatitis is debated. A prospective, randomized, clinical study of early and delayed surgery was done
to delineate the influence of the timing of surgery in the treatment of this disease in 165 patients. Early surgery was defined as that done within 48
hours of admission; delayed was that done more than 48 hours after admission. Ranson''s prognostic signs of severity of disease were used to
categorise patients into 2 risk groups-those with mild and those with severe pancreatitis.
17. IN patients with mild pancreatitis the timing of surgery appeared to have little effect on the outcome. IN patients with severe pancreatitis, early
surgery resulted in a significant increase in morbidity and mortality. Edematous of hemorrhagic necrotizing pancreatitis could develop, with or
without impacted stones, early or late in the progression of the disease, during early or delayed surgery.
18. ALTHOUGH a gallstone initiates a bout of pancreatitis, it does not cause disease progression. The fate of the progression of pancreatitis
appears to be decided early by the amount of digestive enzymes being activated. Early removal of an impacted stone did not ameliorate the
progression of pancreatitis. Surgery should be done during the initial hospital admission after the pancreatitis has subsided.
In ''Davis-Christopher Textbook of Surgery'' Edited by David C. Sabiston, Jr. M.D. 12th Edition, the learned authors observed thus,
.....No deaths resulted in a group of patients with comparably severe pancretitis not undergoing surgery. It would seem reasonable to conclude
that while biliary tract surgery can be safely performed in patients with mild pancreatitis, until further data are available, patients with severe
pancreatitis and biliary tract lithiasis are best managed by supportive treatment. When the acute episode of pancreatitis resolves, surgical correction
of the biliary disease should be undertaken, since the risk of recurrent pancreatitis can be significantly reduced. Even more controversial have been
the various surgical techniques recommended for use in those patients with pancreatitis who are progressively deteriorating : Most of these patients
will be found to have a fatal form of necrotising pancreatitis. In an effort to put the gland at complete functional rest. Lawson and his associates
developed the ""triple ostomy"" procedure (cholecystectomy, gastrotomy, and feeding jejunostomy). Removal of necrotic pancreas by near-total and
total pancreatectomy has also been advocated, but these approaches have not gained any appreciable acceptance. Other approaches have been
those of sump drainage and peritoneal lavage. Lavage has been shown to significantly reduce early mortality in these desperately ill patients.
Unfortunately, peritoneal lavage did not prevent pancreatic necrosis and subsequent mortality from invasive infection. Mortality rates for each of
these techniques range 30 to 60 per cent. Although such rates may seem distressingly high each technique claims improvement over the results in
untreated cases. In summary, the role Of surgery in the treatment of acute and acute relapsing pancreatitis has not been established with certainty.
Although they constitute persuasive testimonials in terms of possible future therapeutic directions, neither these nor other reported surgical
experiences are properly controlled evaluations of the potential benefits of surgical therapy compared to standard supportive treatment
In Bockus Gastroenterology, 5th Edition, Edited by J. Edward Berk, Vol. 6 it was opined :
Advocates in pancreatic resecton in pancreatitis have thus far failed to define the criteria for selecting patients for operation. There have been no
proven clinical or laboratory indices for anticipating pancreatic necrosis. Most studies depend on ""clinical judgment
19. IN Gastrointestinal disease 4th Edition, edited by Edward Wickland it was observed that peritoneal lavage peritoneal dialysis have been
evaluated and the prepondence of the evidence was against their value in decreasing mortality rate. The observations are reproduced hereunder : -
Patients who are still hypotensive afrer adequate volume replacement require placement of a Swan-Ganz catheter and a trial of intravenously
administered pressor substances, such as depamine or isoproterenol hydrochloride (Isuprel). With persistent hypotension and clinical deterioration
during the early course of acute pancreatitis, the issue arises whether removal of the pancreatic exudate or of the necrotic pancreas will benefit the
patient. To this end, peritoneal lavage peritoneal dialysis, sump drainage of the necrotic pancreas and partial to total pancreatectomy have been
evaluated in largely uncontrolled clinical studies. Although to consensus exists regarding the merits of any one of these procedures the
preponderance of the evidence argues against their value in decreasing mortality rate or the frequency of subsequent pancreatic abscess formation.
As a general rule, surgical intervention should be reserved for those situations in which secondary infection in and around the pancreas is known to
be present, or, at least, strongly suspected."" (page 1834)
In Pancreatitis 1989 Ed. (Supra) supportive treatment for the disease has been presented. The relevant observations are as follows : -
..Because of the lack of information concerning pathogenetic mechanisms, the current treatment of pancreatitis is purely supportive; there is no
accepted effective treatment to interrupt the disease process once it is initiated. Hopefully, with increased understanding of the pathophysiology,
gained in large part through animal studies, development of an effective therapy will be possible during the next decade.
(see page 25)
20. IN ''Hardy''s Text Book of Surgery'' 1988 Ed. some controversy regarding the proper timing of surgery in this disease if there is progressive
deterioration inspite of supportive treatment has been noticed. It is observed by the learned author : -
Moynihan in 1925 championed the use of surgery, advising wide drainage of the lesser sac in all patients with acute pancreatitis. However,
multiple studies since that time have suggested that routine operative intervention is of no value and may lead to an increase in morbidity and
mortality. It is for this reason that surgery is reserved for specific indications in patients with acute pancreatitis. The current indications (Table 28-5)
for operative intervention in the management of acute pancreatic include (1) uncertainty of diagnosis, (2) treatment of pancreatitis sepsis, (3)
correction of associated biliary tract disease, and (4) progressive clinical deterioration despite optimal supportive care. There is little controversy in
the literature about the need for operative intervention in patients with the first two indications that is, in patients with uncertain diagnosis or with
pancreatic sepsis. However, controversy does exist concerning the proper timing for surgery in patients with associated biliary tract disease or in
patients undergoing progressive clinical deterioration despite optimal supportive care.
(see page 705) It is proper to make reference now to the following observations in Clinical Gastroenterology second Edition by Howard M. Spiro
: -
Plying their trade with vigor, some surgeons have again revived the possibility of early laparotomy in patients with acute pancreatitis, a ghost not
uncommonly raised from its best resting place. What usually happens is that a surgeon explores a patient on a mistaken diagnosis, finds acute
pancreatitis, catheterizes the duct, washes out the peritoneum, or otherwise interfers with nature''s course, and yet the patient recovers. Because
the therapy of acute hemorrhagic pancreatitis leaves much to be desired, what has seemed to succeed once is repeated again until, after the next
10 or 15 patients have been so treated, it has become apparent that little has been accomplished except to dirty a few more operating rooms.
Xxxx xxxxxx Xxxxx Xxxx xxxxxx Xxxxx The pendulum has begun to swing away from early surgery once again as the fact is recognized that the
natural history of the severely ill patient seems to be unaffected by medical or surgical maneuvers and as it is becoming more clear that adding to
the patient''s burden by operating on his belly does not add to his likelihood on survival.
(See page 1027)
It is evident from the medical opinion almost all the above well-known books, that in the case of acute pancreatitis, the supportive treatment and
not the operation has been advised in the 1st instance. In some of them caution has been given that of operation was performed on the patient in
such circumstances that may contribute to an early death.
Mr. Bhandari submits that it has been held by the various Courts that it is not safe to reply on expert''s evidence and therefore, it will not be proper
to rely upon the statement of Dr. T. Singh. In support of his contention he placed reliance on Fakhruddin v. State of Madhya Pradesh AIR 1967
SC 1326 and in Chuni Lal & Ors. v. State of Haryana 1977 Criminal Law of Journal (Notes) 57. In the former case the Supreme Court was
dealing with the opinion of a hand-writing expert. It was observed there that where an expert''s opinion was given the Court must see for itself and
with the assistance of the expert come to its own conclusion whether it can safely be held that the two writings were by the same person. It was
further observed that the Court was not required to play the role of an expert but the Court should accept the facts proved only when it had
satisfied itself that it was safe to accept the opinion whether of the expert or other witnesses. The observations are unexceptionable. In Chuni Lal''s
case it was held that the Court was not to surrender its own judgment to that of the expert or delegate its authority to a third party but should
assess his evidence like any other evidence. There is no dispute about the correctness of the said observations as well.
21. THE facts of the case have already been given in detail. THE disease in this case had taken a fulminant course. THE course adopted by Dr.
Singh for treatment of the disease in fully supported by the well-known treatises, quotation from which have been reproduced above. He is highly
qualified person and is an eminent surgeon. In the circumstances, he cannot be held guilty of any negligence. Now the matter may be examined
from another point of view. It is, that if two courses were open to Dr. Singh firstly the supportive treatment and secondly operation and one of
them has been taken by him, whether he can be held guilty of negligence A medical person is required to exercise a reasonable degree of skill and
knowledge. It is not possible for him to cure all patients. If a patient dies due to his lack of skill or knowledge, he is liable to pay damages, but not
otherwise. THE law does not require highest degree of competence from a medical person. He is answerable when he falls below the standard of
a reasonably competent medical person or he departs from a normal course. I am fortified in my view from the observations in Bolam v. Friern
Hospital Management Committee (1957) 2 All. ER118, by Mc Nair J. while he was explaining the law to the jury : - ""...where you got a situation
which involves the use of some special skill or competence, then the test whether there has been negligence or not is not the test of the man on the
top of the Clapham omnibus, because he has not got this special skill. THE test is the standard of the ordinary skilled man exercising and
progressing to have that special skill. A man need not possess the highest expert skill at the risk of being found negligent. It is well-established law
that it is sufficient if he exercises the ordinary skill of an ordinary competent man exercising that particular art. I do not think that I quarrel much
with any of the submissions in law which have been put before you by Counsel. Counsel for the plaintiff put it in this way, that in the case of a
medical man negligence means failure to act in accordance with the standards of reasonably competent medical men at the time. That is a perfectly
accurate statement, as long as it is remembered that there may be one or more perfectly proper standards; and if a medical man conforms with one
of these proper standards men he is not negligent. Counsel for the plaintiff was also right, in my judgment, in saying that a mere personal belief that
a particular, technique is best is no defence unless that belief is based on reasonable grounds. That again is unexceptionable. But the emphasis
which is laid by Counsel for the defendants is on this aspect of negligence; He submitted to you that the real question on which you have to make
up your mind on each of the three major points to be considered is whether the defendants, in acting in the way in which they did, were acting in
accordance with a practice of competent respected professional opinion. Counsel for the defendants submitted that if you are satisfied that they
were acting in accordance with a practice of a competent body of professional opinion, then it would be wrong for you to hold that negligence was
established."" Mc. Nair, J. in the course of the same address made reference to the observations of Lord Clyde in Hunter v. Hanley I (1955) S.L.T.
213 (217) which were as follows;
In the realm of diagnosis and treatment there is ample scope for genuine difference of opinion, and one man clearly is not negligent merely because
his conclusion differs from that of other professional men, nor because he has displayed less skill or knowledge than others would have shown.
THE true test for establishing negligence in diagnosis or treatment on the part of a doctor is whether he has been proved to be guilty of such failure
as no doctor of ordinary skill would be guilty of, if acting with ordinary care.
After-referring to the Lord Clyde''s observations, he says,
I myself would prefer to put it this way : A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a
responsible body of medical men skilled in that particular art. I do not think there is much difference in sense. It is just a different way of expressing
the same thought. Putting it the other way round, a doctor is not negligent, if he is acting in accordance with such a practice, merely because there
is a body of opinion that takes a contrary view. At the same time, that does not mean that a medical man can obstinately and pig-headedly carry on
with some old technique if it has been proved to be contrary to what is really substantially the whole of informed medical opinion. Otherwise, you
might get men today saying : ""I don''t believe in anesthetics. I don''t believe in antiseptics. I am going to continue to do my surgery in the way it was
done in the eighteenth century."" That clearly would be wrong.
Similar opinion has been emphasised by Lord Denning in Kucks v. Cole (1968) 118 New LJ 469. THE relevant observations are as follows : -
A charge of professional negligence against a medical man was serious. It stood on a different footing to a charge of negligence against the driver
of a motor car. THE consequences were far more serious. It affected his professional status and reputation. THE burden of proof was
correspondingly greater. As the charge was so grave, so should the proof be clear. With the best will in the world, things some times went amiss in
surgical operations or medical treatment. A doctor was not to be held negligent simply because something went wrong. He was not liable for
mischance or misadventure; or for an error of judgment. He was not liable for taking one choice out of two or for favouring one school rather than
another. He was only liable when he fell below the standard of a reasonably competent practitioner in his field so much so that his conduct might be
deserving of censure or inexcusable.
To the same effect are the observations in Dr. Laxman Balkrishna Joshi v. Dr. Trimbak Bapu Godbole AIR 1969 Supreme Court 128. THE
following dictum of Shelat J. while speaking for the Court may be read with advantage : -
THE duties which a doctor owes to his patient are clear. A person who holds himself out ready to give medical advice and treatment impliedly
undertakes that he is possessed of skill and knowledge for the purpose. Such a person when consulted by a patient owes him certain duties, viz., a
duty of care in deciding whether to undertake the case, a duty of care in deciding what treatment to give or a duty of care in the administration of
that treatment. A breach of any of those duties gives a right of action for negligence to the patient. THE practitioner must bring to his task a
reasonable degree of skill and knowledge and must exercise a reasonable degree of care. Neither the very highest nor a very low degree of care
and competence judged in the light of the particular circumstances of each case in what the law requires : (cf. Halsbury''s Laws of England, 3rd ed.
vol. 26 p. 17). THE doctor no doubt has a discretion in choosing treatment which he proposes to give to the patient and such discretion is
relatively ampler in cases of emergency.
22. I am in respectful agreement with the above observations. After taking into consideration all the aforesaid circumstances I am of the view that
Dr. T. Singh can be held guilty of negligence if he did not perform operation on the deceased. 50. Now it is to be seen whether peritoneal lavage
should have been done on the patient. Mr. Bhandari, to support his contention that the peritoneal lavage should have been done relied on the
observations in Maingot''s Abdominal Operations 8th Edition, Vol. 2 at page 2070. ""Peritoneal lavage is usually associated with a marked
improvement in the early systemic manifestations of severe pancreatitis. In nonlavaged patients, approximately 40 per cent of all deaths occur
during the first 10 days of treatment and are primarily due to respiratory and cardiovascular failure. Peritoneal lavage has been an extremely
effective adjunct to the management of these complications and had been associated with almost complete prevention of eatly deaths.
On the other hand Mr. Parikh, the learned Counsel for respondent No. 2 has submitted that peritoneal lavage would not have been of any
advantage to the deceased. In support of his contention he places reliance on Gastrointestinal Diseases 4th Edition (supra). It is observed there that
peritoneal lavage has been evaluated in largely uncontrolled clinical studies. Although no consensus exists regarding the merits of any one of these
procedures, the preponderance of the evidence argues against their value in decreasing mortality rate. The para has been reproduced at page 29 of
the judgment. The book was published in 1989 and thus contains the latest view on the point. From the aforesaid two views it is evident that the
medical opinion on this point varies. Dr. T. Singh, in view of his own experience, followed the view given in Gastrointestinal Disease. It has already
been discussed that if two courses are open to a medical person and he adopts one of them it can not be held that he is guilty of negligence.
Therefore, I am of the view that Dr. T. Singh is not guilty of negligence on the ground that he did not do peritoneal lavage on the patient.
For the aforesaid reasons I partly accept the claim of the complainant with costs and direct respondent Nos. 1 & 2 to pay Rs. 80,000/- and Rs.
20,000/- respectively to the complainant within a period of two months. Costs Rs. 2,000/-. Respondent No. 1 shall pay Rs. 1,600/- and
respondent No. 2, Rs. 400/- out of the costs. B.L. Anand, Member I have examined the record and the pleadings of the parties in the context of
the above drawn findings. I am in agreement with regard to the conclusions on the various contentions and issues discussed in details as above but
I am not inclined to hold respondent No. 2 Dr. T. Singh guilty for any act of negligence. In the first instance Dr. T. Singh, respondent No. 2 was
not the only doctor attending on the deceased, Sh. Rajesh. There was a team of equally qualified and eminent doctors consisting of Dr. Minocha
M.S, Dr. R. Sarangi M.S, Dr. P.S. Gupta, Dr. S.P. Byotra, Dr. Samir Kapoor and others looking after the patient. As per hospital records and
history sheet in addition to respondent No. 2, other doctors also recommended shifting of the patient to ICU. It was respondent No. 1, the
hospital, who was responsible for providing all the para medical facilities like ICU, Nursing care and equipments etc. For arguments sake in case
respondent No. 2 was in any way though to be responsible and guilty of any negligence it would be naked discrimination to exclude other doctors
from this act of omission and under that situation the complainant should have impleaded other concerned doctors also in this case and not singled
out respondent No. 2. The position of Dr. T. Singh, respondent No. 2, could at best be compared to that of a captain at the war front where the
captain orders the soldier to fire which orders were disobeyed. In that situation should the captain be court marshalled or the soldier who
disobeyed; For all intents and purposes it is the hospital, respondent No. 1, who failed and neglected to provide the ICU bed which could have
prolonged the precious life of Sh. Rajesh, the deceased.
23. IN view of the above discussed facts I hold respondent No. 1, the hospital, to be exclusively responsible for the guilt/negligence for not
providing the required ICU facilities to the patient and as such I direct respondent No. 1 to pay the entire compensation of Rs. 1 lakh to the
complainants alongwith the costs of Rs. 2,000/-. Dr. (Mrs.) Avtar Pennathur, Member I have read the orders. I agree with Mr. Anand and also
old that the entire compensation of Rs. 1 lakh be paid to the complainants by respondent No. 1, alongwith costs of Rs. 2,000/-. Ordered
accordingly.