Dr. S.M. Kantikar, Presiding Member
1. This Complaint has been filed under Section 21 of the Consumer Protection Act, 1986 (for short ‘the Act’) by Punit Goyal (the Complainant) against Dr. Mridula Vohra, and Bhagirathi Neotia Woman and Child Care Center (the Opposite Parties) seeking compensation of Rs. 20 Crore for the alleged death of his wife Jyoti Goyal due to the gross medical negligence during second delivery.
2. The Complainant’s wife Jyoti Goyal, during 2nd pregnancy, was under care of Dr. Mridula Vohra (OP-1). Her expected date of delivery (EDD) was in September, 2014. She was diagnosed as ‘Placenta Previa /Accreta’, but it was allegedly never disclosed by OP-1. On 14.07.2014, due to acute lower abdomen pain, the patient was admitted in the OP-2 Hospital. The patient was in stable condition, no bleeding and no scar tenderness. The OP-1 did not perform USG and the Duvadilan (R) Test prior to delivery on previous night. It was alleged that the OP-1 never disclosed about the high risk of PPH, blood transfusions and possible need for emergency Hysterectomy. The OP did not take ‘High Risk Consent’ for Hysterectomy.
3. The C-section was performed on 15.07.2014. After delivery the patient had profuse bleeding, which could not be stopped. The OP-1 tried to remove the adherent placenta in the small pieces (“Piecemeal”), the bleeding increased further leading to hemorrhagic shock. It was alleged that necessary arrangement of blood and/or its products was not made, but OP-1 hurriedly started Emergency Hysterectomy which further precipitated hemorrhagic shock leading to Cardiac arrest and death in the OT. The OPs obtained signature from Complainant for Hysterectomy by misrepresenting the facts.
4. The Complainant further submitted that the Deputy Director of Health Service (Admin) Department of Health, Govt. of West Bengal enquired the matter and affirmed that OP-1 failed to provide rational treatment in the case.
5. Being aggrieved by the gross medical negligence on the part of Opposite Parties, this Consumer Complaint was filed.
6. In the defense, the Opposite Parties filed their respective replies and denied the allegations of medical negligence.
7. Dr. Mridula Vohra (OP-1) raised the preliminary objection on maintainability of Complaint that it was barred by limitation u/s 24 of the Act. It was filed with a delay of about 403 days. The OP-1 submitted that the deceased was a house wife, but the Complaint was filed with inflated and imaginary claim. She narrated the details of patient’s treatment as under:
a. Patient namely Jyoti Goyal admitted at Bed No ICU 1 under OP no. 1 – Dr. Mridula Vohra for pregnancy and the treatment provided was the best possible that could have been done. Patient had history of past CS with placenta previa in current pregnancy and so the patient and husband were counseled by Dr. Vohra - OP no. 1 that in cases of early detection of placenta previa (during 14 to 16 weeks of pregnancy), the placenta may migrate upwards as the pregnancy progresses but around in 5 to 10 % cases placenta remains previa, as has happened in the present case. Patient always presented BP of 80/60 - 90/60 mm of Hg throughout the tenure of pregnancy.
14th of July 2014
b. 4:15 PM Patient came in with complaint of pain abdomen since morning and hence was taken to Labour Room. Initial Assessment was done in the Labour Room itself at 4:15PM where findings revealed no scar tenderness and no contractions. Injection Drotin stat was administered and bed rest was advised as per OP No. 1, Dr. Mridula Vohra.
c. At 4:31PM; patient was admitted at Bed No LR 1.
d. 6 PM: RMO saw the patient again at 6 PM when patient condition was well. No scar tenderness, patient on normal diet and complete bed rest. Patient complained of intermittent pain abdomen.
e. At 9PM patient was seen by Dr. Mridula Vohra - OP no. 1 when patient was well with no contractions. Toilet facilities were allowed and USG was advised coming morning.
15th of July 2015
f. 7AM: RMO seen the patient. Complaints of intermittent pain abdomen, scar tenderness nil.
g. 9:20AM: Case was seen by Dr Mridula Vohra - OP no. 1. Contractions ++, Scar tenderness ++ Patient was having pain and thus instead of doing USG the decision of Emergency LUCS was taken by Dr Vohra and the patient party was informed by Consultant to come over Immediately.
h. 10:45AM: once the patient party arrived OT started. After opening the abdomen, when lower segment was incised there was profuse bleeding. Baby was extracted after cutting through the placenta. Baby was handed over to the pediatrician. Placenta and membranes expelled, placental bed was repaired and uterus closed in layers. Uterus was well contracted and there was no bleeding.
i. 11:40AM. Abdomen was closed in layers after proper haemostasls. During the surgery the BP dropped for which supportive treatment was administered. BP rose to 130/60 mm of Hg and patient again started bleeding profusely. Bimanual compression did not help and Consultant took the decision for Hysterectomy. The same OT followed into Hysterectomy. Party was informed about PPH (Post-Partum Hemorrhage). Complainant's consent for Hysterectomy was taken. As per operative doctor's advice blood was arranged by the hospital with minimal timing from the institute Mission of Mercy Hospital which is situated opposite to OP no 2 hospital with the minimum time taken for sample cross matching. Per operative 4 units (2 units of whole blood and 2 units of PRBC) were received and was transfused to the patient starting from 12 Noon, 2nd bottle at 12:30 PM, 3rd bottle at 12:45PM and 4th bottle at 1:05PM. Blood was arranged within 15 to 30 minutes post order of the Consultant from Mission of Mercy Hospital and transfusion was started immediately. There was no delay in arrangement and Transfusion of blood. FFP (Fresh Frozen Plasma) was also arranged as per Consultant's advice in case of requirement for eventuality,
j. 1:10 PM: Patient received by ICU. Manual ventilation, pupil mid dilated, put on ventilation CMV mode,
k. 2 PM: Blood Transfusion continued till 2PM. 2:15 PM Cardiac Arrest occurred. CPR started. Pulse and BP not palpable and recordable. CPR was given continuously. Adrenaline and Atropine administered followed by Cardiac shock with short recovery period with Pulse 30/min. Atropine given. Pulse 60 / min. BP not recordable.
l. 2:30 PM: 2nd Cardiac Arrest occurred. CPR done continuously as per ACLS guidelines but BP and pulse not recordable.
m. 2:45 PM: patient clinically declared dead and the same was informed to patient party.
8. The Bhagirathi Neotia Woman & Child Care Centre (OP-2) adopted the version filed by the OP-1. It was submitted that OP-2 Hospital is a specialized hospital offering the most advanced facilities for woman and child care in Eastern India. The patient was given utmost care and treatment as per the standard medical protocols.
9. I have heard the arguments from the learned Counsel for both the sides. Perused the material on record, inter alia, the Medical Record. The learned Counsel on both the sides reiterated their evidence.
10. The learned Counsel for the Complainant argued the OP-1 failed to take proper care during pregnancy with Placenta Previa. He submitted that the OPs forced the Complainant to give their consent for hysterectomy.
11. The learned Counsel for OPs reiterated their evidence. The OPs filed medical literature on PPH and few citations.
12. I have perused the entire medical record. The patient was diagnosed with Placenta Previa and she was under follow up throughout ANC period. It was not a case of Placenta Acreta, therefore MRI was not done. In my view, the OP-1 took timely decision to perform LUCS (LSCS-Caesarian Section). The patient developed PPH and the hospital arranged blood from the Mission of Mercy Hospital. From 12 Noon 2 units of whole blood and 2 units of PRBC were transfused. There was no delay to arrange and transfuse the blood. Fresh Frozen Plasma (FFP) was also arranged. I have perused the informed consent for LUCS (LSCS) and the emergency hysterectomy. I do not find any breach in duty of care from the OP-1 who took correct decision during emergency.
13. To know about the PPH and Postpartum Hysterectomy, I have gone through few medical articles, WHO recommendation and the William’s Obstetrics (14th Ed.) textbook and the Johns Hopkins Manual of Gynecology and Obstetrics (5th Ed.).
13.1 The Postpartum haemorrhage (PPH) is known as an Obstetric haemorrhage is associated with increased risk of serious maternal morbidity and mortality. As per WHO, the PPH is generally defined as blood loss greater than or equal to 500 ml within 24 hours after birth, while severe PPH is blood loss greater than or equal to 1000 ml within 24 hours. PPH is the most common cause of maternal death worldwide. Most cases of morbidity and mortality due to PPH occur in the first 24 hours following delivery and these are regarded as primary PPH whereas any abnormal or excessive bleeding from the birth canal occurring between 24 hours and 12 weeks postnatally is regarded as secondary PPH. PPH may result from failure of the uterus to contract adequately (atony), genital tract trauma (i.e. vaginal or cervical lacerations), uterine rupture, retained placental tissue, or maternal bleeding disorders. Uterine atony is the most common cause and consequently the leading cause of maternal mortality worldwide.
13.2 WHO Recommendation
If bleeding does not stop in spite of treatment with uterotonics, other conservative interventions (e.g. uterine massage), and external or internal pressure on the uterus, surgical interventions should be initiated. Conservative approaches should be tried first, followed – if these do not work – by more invasive procedures. For example, compression sutures may be attempted first and, if that intervention fails, uterine, utero-ovarian and hypogastric vessel ligation may be tried. If life-threatening bleeding continues even after ligation, subtotal (also called supracervical or total hysterectomy) should be performed.(extracts from WHO guidelines for the management of postpartum haemorrhage and retained placenta).
3 Postpartum Hysterectomy:
Postpartum hysterectomy refers to hysterectomy done after vaginal delivery or caesarean delivery. In modern obstetric practice, it is a major operation being associated with a high rate of morbidity and mortality. The major indications for emergency postpartum/obstetric hysterectomy (EOH) include placenta previa; placenta accreta, increta, and percreta; and uterine rupture. Thus, most of such hysterectomies are unplanned and often performed as an emergency for obstetric haemorrhage which doctors are unable to stop or there is undiagnosed abnormal placentation. The most common indication of EOH was uterine atony (25%) followed by morbidly adherent placenta (21%) and uterine rupture (17%).In spite of the availability of uterotonics agents and a variety of uterus sparring surgical interventions, the obstetrician will be faced with the dilemma to choose a conservative or an aggressive management. The treating doctor/surgeon is sometimes in a dilemma whether to sacrifice a woman’s reproductive capability especially if she is of low parity. It also depends upon the woman’s desire for preserving fertility but further delay in emergency postpartum hysterectomy may lead to severe morbidity or maternal death. If all attempts at arresting bleeding have failed, subtotal or total hysterectomy is attempted as a last resort and life-saving measure.
· The preoperative risk factors include previous history of caesarean section, placenta previa and accreta. Obstetric shock index may help in avoidance of under estimation of blood loss and the use of tranexamic acid, oxytocic and timely peri-partum hysterectomy will help to save lives. Due to the complexity of the surgery and decision making, the involvement of an experienced obstetrician at an early stage is desirable.
· The life-threatening haemorrhage i.e. in cases of haemodynamic instability the decision to perform a hysterectomy should not be delayed. Therefore subtotal hysterectomy is preferred because it is associated with minimal risk of visceral injuries and blood loss. It needs short operating time and hospital stay. It is known that women with abnormal placental adhesion were approximately two times more likely to undergo total than subtotal hysterectomy. The decision to escalate surgical management to hysterectomy should be made by the most senior and experienced obstetrician.
13.4 In view of the aforesaid it is submitted that the Opposite Parties while treating the patient has acted in a manner which is acceptable to the medical profession and the has attended on the patient with due care, skill and diligence, hence there is no medical negligence on the part of the Opposite parties and therefore the present complaint may be dismissed.
14. It should be borne in mind that the skill of the doctor differs from each other as there may be more than one course of treatment which may be advisable for treating a patient. Thus, if the doctor performs his duties to the best of his ability and with due care and caution, negligence can’t be attributed to him[Achutrao Harbhau Khodwa Vs. State of Maharashtra - (1996) 2 SCC 634]. In Jacob Matthew v. Union of India (2005) SCC (Crl.) 1369, Hon’ble Supreme Court observed as under:-
"25......At times, the professional is confronted with making a choice between the devil and the deep sea and he has to choose the lesser evil. The medical professional is often called upon to adopt a procedure which involves higher element of risk, but which he honestly believes as providing greater chances of success for the patient rather than a procedure involving lesser risk but higher chances of failure. Which course is more appropriate to follow, would depend on the facts and circumstances of a given case. The usual practice prevalent nowadays is to obtain the consent of the patient or of the person in-charge of the patient if the patient is not be in a position to give consent before adopting a given procedure. So long as it can be found that the procedure which was in fact adopted was one which was acceptable to medical science as on that date, the medical practitioner cannot be held negligent merely because he chose to follow one procedure and not another and the result was a failure."
15. I have perused the report dated 07.02.2017, issued by the Dy. Director of Health Service (Admin) West Bengal, which held Dr. Vohra failed to provide rational treatment in the instant case. In my opinion, the report was inadequate without discussion and one sided. Moreover, the opposite parties were not heard. Thus, it was one sided and issued without following the principles of Natural Justice. It can’t be taken as evidence.
16. The Hon’ble Supreme Court in the case of Bombay Hospital and Research Medical Centre vs. Asha Jaiswal & Ors [2021 SCC OnLine SC 1149] observed that:
“if the patient was in a critical condition and he could not survive even after surgery, keeping that in mind the blame cannot be passed on to the Hospital and the Doctor who had provided all possible treatment within their means and capacity to diagnose the patient of this illness. The family may not have coped with the loss of their loved one, but the Hospital and the Doctor cannot be blamed as they had provided the requisite care at all given times.”
17. It is evident that, the instant complaint was filed after three years from the cause of action (date of death of the patient. Even the FIR also was filed 2 years after the death of the patient. It appears to be an afterthought decision to approach this commission with the highly inflated claim of Rs. 20 Crores. The prayer is just imaginary without justifications.
18. Based on the foregoing discussion, in the obtaining facts and circumstances and following the precedents, it is not feasible to attribute negligence / deficiency on the opposite parties. The Complainants have failed to establish deficiency / negligence against the treating doctors. On the contrary, I find the Complaint to be misconceived.
19. The Complaint is dismissed as barred by limitation as well as bereft of merit.
There shall be no Order to cost.
