Mrs. M. Shreesha, Incharge, President:
1. Aggrieved by the order in C.D. No. 82/2001 on the file of District Forum, Ranga Reddy District, opposite party No. 1 preferred this appeal.
2. The brief facts as set out in the complaint are that the complainants daughter, Ms. Kavita, consulted Dr. Sudheer Goje of Bodhan on 7.4.2000 with a complaint of chest pain. After examining the patient, he gave some medicines and advised to undergo some tests but as the patient did not respond to the treatment and on his advice approached Dr. Shyam Sunder of Medwin Hospital, Hyderabad i.e. opposite party No. 1. Opposite party No. 1 treated her as out-patient on 17.4.2000 and as initial diagnosis observed that there are no cervical glands and lungs were normal and advised to use medicines for one week as per O.P. card and come for review after four days without prescribing air-bronchogramme. Blood examination was done on 17.4. 2000 at opposite party No. 3 diagnostic centre revealed that ESR level was on higher side, on 18.4.2000 bronchoscope test was conducted at opposite party No. 1 hospital and it was diagnosed as Hyperemia post-set of RVL. On the same day pathological test i.e. cytology for any fluid was done and it was observed no significant inflammation or evidence of malignancy. AFB stain test was done and the report revealed ânegative for fungal evidence. On 20.4.2000 CT Scan for chest (Plain study) was conducted and the report revealed âMild Spleenomegalaeâ and suggested for clinical correction. The patient was prescribed some medicines but when there was no relief, she approached opposite party No. 1 on 22.5.2000 with a complaint of vomitings, and pain in the abdomen. The complainant submitted that the problem was diagnosed as âDrug induced Hepatitis and advised to stop ATT and prescribed to use some more medicines and advised blood test, liver function test for serum electrolytes. The blood report once again revealed that ESR level was very high and Liver function test suggested for clinical correlation and opposite party No. 1 referred the patient to opposite party No. 2 hospital for admission and treatment. The patient was subjected to CBP test on 22.5.2000 for investigation of blood for HIV 1 and 2 and HBs Ag and the report dated 23.5.2000 was negative. The report dated 26.5.2000 showed that SGPT and alkaline phosphates were high. Opposite party No. 2 doctor referred to opposite party No. 4 diagnostic centre stating that clinical findings as drug induced Hepatitis and investigations were required like US scan of abdomen and x-ray chest PA view. The ultra sound scan of whole abdomen was done on 29.5.2000 at opposite party No. 4 hospital and the impression revealed âMild Hrepato meagerly-Hepatitis, mild spleeonomegaly and bilateral pleural effusion for correlation/follow up. X-ray chest PA view impression was âRight Upper lobe opacity âKochs for correlation follow upâ. The complainants submitted that their daughter was in opposite party No. 2 hospital from 22.5.2000 and treated for Pulmonary Kochs and drug induced for gastritis, hepatitis and dermatitis and was going in for GR-1 hepatic encephalopathy and was discharged with an advice to go to Medwin Hospital for further management on 30.5.2000. Since there was no relief, the patient was admitted in opposite party No. 5 hospital and was again subjected to CBP (for RH-D) type), Haematology, Biochemistry and CBU examination, serology, complete blood picture, bio chemistry for blood urea, ultra sound scan-whole abdomen (female) Bio chemistry for potassium, Bio chemistry for âRandom blood sugar on 30.5.2000. The complainant submitted that there was no proper diagnosis or treatment extended by opposite parties 1 and 2 at any stage and their daughter, Ms. Kavita, finally expired on 3.6.2000 at opposite party No. 5 hospital. Hence the complaint for a direction to all the opposite parties to pay the complainants a sum of Rs. 4,80,000 with interest as the Forum deems fit together with costs.
3. Opposite party No. 1 denied the allegations made in the complaint and stated that there was no negligence or deficiency of service in treating the patient. He submitted that the patient discontinued her treatment with him much prior to her demise and that he was not aware of the treatment taken by her at Remedy Hospital and submitted that the patient and her parents did not follow the advice given by him. He submitted that the negligence is on the part of the complainants in not taking proper follow up treatment for their daughter which resulted in her death. He admitted that the patient was referred to him by Dr. Sudheer Goje of Bodhan and submitted that the patient approached him with complaint of cough pain in the chest, blood vomitings and was weak and anemic. He submitted that extensive investigations did not reveal any uncommon disease and therefore it was a common disease with unusual symptoms and presentation and small investigations could not identify the problem and hence tests like Pneumonia, T.B., PTE, cancer and tumor tests such as Bronchoscope, C.T. scan of the chest and nuclear tests were done and P.T.E., cancer and tumors were excluded and as the ESR level was high, it was an indication for Kochi apart from patchy opacity in lung and on examination of CT scan of chest, bronchial hyperemia, bronchial wash for AFB was negative which can be expected 60% even if the disease is existing. He further stated that he prescribed 4 drugs and ATT for two weeks/one month and asked to come for review if there is any problem but the deceased did not turn up for review and after one month her brother sought advice over telephone for vomitings and pain and submitted that he did not prescribe any medicines and insisted to bring the patient. He submitted that the patient was brought to him on 22.5.2000 and on seeing her the doctor noticed the side effects of the drugs and she was diagnosed as suffering from ATT induced hepatitis which is common to occur in 5 to 10% of patient and he immediately advised her to stop ATT and get admitted in Medwin Hospital for check up and intensive care to know the extent of damage to the liver due to side effects. Opposite party No. 1 submitted that due to financial constrains the patient and her brother refused the offer and requested for a small hospital and he submitted that had the patient been brought immediately the damage would have been minimum and under control. He submitted that the patient was admitted in opposite party No. 2 hospital and her condition deteriorated further in spite of giving hepatic protection to liver and the patient developed gastritis and dermatitis as endorsed by Specialist in Gastro Entamologist, Dr. Panduranga Rao. He submitted that when the condition of the patient further deteriorated with Hepatic encephalopathy, the patients attendants were asked to shift the patient to Medwin but they refused and absconded from opposite party No. 2 hospital and got the patient admitted in opposite party No. 5 hospital where the patient died. He further submitted that he is a post graduate i.e. M.D. from Osmania Medical College in 1991 and subsequently worked as Senior Registrar in Respiratory Medicine at NIMS from 1991 to 1993 and later did his super specialty in pulmonary medicine at P.G.I., Chandigarh from 1993 to 1995 and is one of the foremost persons in South India with highest qualifications and done diploma in National Boards in Respiratory Medicine in 1992 and working from 1995 till date in Medwin Hospital and got vast experience of 15 years in managing various respiratory diseases and prayed for dismissal of the complaint.
4. Opposite party No. 2 filed counter stating that they have treated the patient with utmost care for drug induced hepatitis and necessary tests were conducted and the patient was diagnosed as suffering from drug induced hepatitis Gr-l encephalopathy and advised her to be admitted in Medwin Hospital but the attendants took the patient to Remedy Hospital against the advice of opposite party No. 1 and submitted that there is no negligence and prayed for dismissal of the complaint.
5. Opposite party No. 3 right for filing counter was forfeited on 25.11.2002.
6. Opposite party No. 4 filed counter stating that their role is only to the extent of taking x-ray chest and nothing to do with the treatment of the patient.
7. Opposite party No. 5 filed counter and admitted that the patient joined in their hospital on 30.5.2000 at about 11.00 a.m. and her problem was diagnosed as âHepatic encephalopathyâ and obtained opinion from Dr. Panduranga Rao, who opined that it is a case of âFulminant Hepatic Failureâ Grade III encephalopathy and explained the prognosis to the attendants. They submitted that the patient was managed in ICU but her condition deteriorated and expired on 3.6.2000. They submitted all the investigations carried on the patient normally diminishes the liver failure and deficiency of this fact causes bleeding from multiple sites in human body and this was corrected by giving injection Vitamin âK and plasma which causes synthesis and to monitor the matter in its value, these investigations have to be carried out regularly. They submitted at no point of her stay attention was reduced and submitted that there is no medical negligence on their part and prayed for dismissal of the complaint.
8. Aggrieved by the said order, opposite party No. 1 preferred this appeal.
9. The learned Counsel for the appellant submitted that the respondents/complainants failed to establish that the deceased was not suffering from tuberculosis or that the diagnosis and the treatment given was wrong. He further contended that there is no expert evidence to show that the diagnosis and the treatment given were wrong. The learned Counsel submitted that the patient was explained about the side effects and was asked to stop medicines and come immediately in case of side effects and the deceased did not do so. When the treatment and the risks involved were thoroughly explained to the patient and her attendant before starting ATT medicines, he submitted that there is no negligence on his behalf. Investigations such as Mantoux, T.B. serology, LFT were not done at the patients brother stated that they could not afford the same. He also submitted that the deceased and her brother were well educated and ATT drugs are available in combi packs in 30 packs for 30 days i.e. one pack per day and as such the timings were not written down and if at all the patient did not understand nothing prevented the patient from enquiring from the doctor with respect to usage. He further contended the patient had chest pain, haemoptysis, raised ESR level, consolidation in RU2 on CXR, CT hyperemia in Bronchoscopy which are all suggestive of tuberculosis and submitted that there is no deficiency of service and prayed for dismissal of the complaint.
10. The learned Counsel for the respondent/complainant filed his written arguments and submitted that without identifying the problem and proper diagnosis, the doctor prescribed ATT drugs and failed to give written instructions to the deceased in what manner the drugs/medicines are to be taken i.e. whether one pack can be used with empty stomach or after meals. The prescription does not show any written instructions. The submission of the appellant that the deceased was given verbal instructions is denied by the respondents/complainants. The learned Counsel for the respondents/complainants further contended that there is no necessity to examine expert witness since there is sufficient evidence on record to come to a conclusion that the doctor is at fault and the hospital is equally at fault to treat the patient without coming to a correct diagnosis. He contended that the patient died of drug induced hepatitis which is a direct consequence of prolonged use of tuberculosis medicines and therefore the doctor is negligent in his treatment and that the District Forum has rightly allowed the complaint.
11. We have gone through the material on record. The facts not in dispute are that the patient, Ms. Kavita, approached the appellant with complaints of cough, pain in the chest, blood vomitings and was weak and anemic. As the patient was not responding to simple antibiotics, bronchoscope, CT scan of the chest and nuclear scan were done. ESR level was high and it was an indication of Kochi apart from patchy opacity in the lung on examination of C.T. scan of chest, bronchial hyperemia bronchial wash for AFB was negative. It is the contention of the appellant that prescribed 4 drugs and ATT for two weeks/1 month and asked the deceased to come for review in case of any problem. The deceased did not turn up for review and her brother was seeking advice over the telephone for vomitings and pain and the deceased visited the appellant on 22.5.2000 and this appellant noticed the side effects were due to drugs and the patient was diagnosed to have drug induced hepatitis, which is common to occur in 5 to 10% of the patients. The appellant submits that had the patient been brought to him physically in time, the danger would have been minimum without the brother wasting time on telephonic treatment. He further contended that it was a difficult case for diagnosis and treatment but Ex. A22 which is referral letter given to the appellant by Dr. Sudheer Goje did not state anything about the case being difficult for diagnosis and treatment.
12. The medical literature i.e. Text book of Pulmonary and Extra Pulmonary Tuberculosis, Page-2 which is as follows:
âMany patients with TB present with general symptoms such as tiredness, malaise, loss of appetite weakness or loss of weight, fever with night sweats specially evening rise may be a characteristic symptom of tuberculosis as described often. Symptoms are most frequently related to the respiratory system with cough as the outstanding manifestation.â
The contention of the appellant that he had prescribed 30 packs which means one pack per day and has explained clearly to the patient, the complications and the risks involved is unsustainable on the ground that the prescription i.e. Ex. A23 is silent about any such instructions given by the doctor to the patient. Moreover, the appellant mentioned in his grounds that instructions are given on the pack and had the patient enquired from him, he would have clarified any further inquiries, clearly indicates that the appellant did not explain to the patient the prognosis and the risks and complications involved in taking the TB drugs. It is admitted by the appellant doctor that the patients brother contacted him over phone with respect to continuous vomitings and pain and at least at that stage the doctor ought to have instructed the patient or her attendant about the side effect of the ATT drug when he himself has admitted that the diagnosis is drug induced hepatitis, it is up to the doctor to explain what steps he has taken to warn the respondent/complainant about the complications. The prescription, we reiterate is silent about any such instructions and ATT was stopped only on 22.5.2000 which shows that the patient was taking medicines prescribed by the appellant from 17.4.2000 to 22.5.2000 for a period of 5 weeks. Had the doctor immediately reacted to the information given by the patients brother that the patients condition did not improve and the vomitings continued, we are of the considered opinion that the damage caused to the liver could have been reduced. The appellant doctor without conducting the mandatory tests required for TB, prescribed the medicines meant for ATT treatment and the condition of the deceased deteriorated. It is also an admitted fact that the patient ultimately died due to Fulminat Hepatice Failure, Grade III Encephalopathy. With respect to the contention of the appellant/opposite party No. 1 that there is no expert evidence in this case, we rely on the principle of res ipsa loquitur which means things appear as they are and in the instant case the patient being treated for tuberculosis is an admitted fact and the side effects caused i.e. drug induced hepatitis is also an admitted fact and, therefore, we agree with the observation of the District Forum that there is no need to examine an expert witness. Taking into consideration that the patient is young and aged 20 years with no high risk complications, we are of the view that the compensation awarded by the District Forum is justified.
In the result, the appeal is dismissed. Time for compliance six weeks.
Appeal dismissed.