2022 (11) TMI 35 - Commission - Indian Laws

Res ipsa loquitur - Breach of duty of care - Alleged gross medical negligence and deficiency in service causing death of their only child during surgery for squint correction - Section 21 of the Consumer Protection Act 1986 - incorrect dosage of atropine and improper timing - HELD THAT - Several studies revealed that there is no uniform fasting practice for children before effective surgery. Fluids in small quantity are acceptable 2-3 hours prior to GA. The Complainant No. 2 (father) signed the Informed Consent. The child was not administered Atropine in correct dose at proper time. There are no importance to the pre-medication by Atropine for Antisialagogues to decrease the flow rate of saliva is not routinely used. In the recent days it is not regularly in practice by the Anesthetist - the Tracheal intubation is a standard technique used during GA. Local anesthesia was not resorted to as it requires the co-operation of the child. The mask anesthesia was not resorted to in any head and neck surgery which also obstructs the surgical field of eyes. Tracheal Intubation may be done under deep inhalation anesthesia (Halothane) or with the use of other muscle relaxants. In the Instant case as the vocal cord was anterior it was not possible to intubate the patient in the first attempt. It is not clear from the record that Scoline was administered before first intubation as such the possibility cannot be ruled out. It was the Oculocardiac Reflex (OCR) also known as the Aschner reflex or trigeminovagal reflex (TVR). It is a reduction in the heart rate secondary to direct pressure placed on the eyeball. It is defined by a decrease in heart rate by greater than 20% following globe pressure or traction of the extraocular muscles. Most commonly the reflex induces bradycardia. However OCR also has a reported association with reduced arterial pressure arrhythmia asystole and even cardiac arrest. This reflex has most notably been depicted during ophthalmologic procedures more specifically during squint/strabismus Ocular Surgery - in the instant case the Intra-Operative diagnosis of OCR was missed and the child suffered Cardiac Arrest. The patients who are considered at-risk for the OCR should warrant particular attention. It is well established that a hospital is vicariously liable for the acts of negligence committed by the doctors engaged or empanelled to provide medical care 2004 (10) TMI 637 - SUPREME COURT . It is common experience that when a patient goes to a hospital he/she goes there on account of the reputation of the hospital and with the hope that due and proper care will be taken by the hospital authorities. If the hospital fails to discharge their duties through their doctors being employed on job basis or employed on contract basis it is the hospital which has to justify the acts of commission or omission on behalf of their doctors - It is held that the OP-1 Sankara Nethralaya to be vicariously liable for the acts of omission and commission committed by the OP-2 and 3 as being jointly and severally liable to pay compensation to the Complainants. Having medical negligence conclusively attributed to the treating doctor at Sankara Nethralaya and having regard to that the Complainants lost their only son in the ends of justice the compensation of Rs. 1 Crore is just and fair in the instant case - since the Cardiologist - Dr. Bhaskaran has not been arrayed as a party therefore monitory liability cannot be fixed upon him and therefore the OP-1 is held vicariously liable. Accordingly we direct the Sankara Nethralaya (OP-1) to pay Rs. 85 lakh; the Anesthetist Dr. R. Kanan (OP-3) shall pay Rs. 10 lakh and the operating Ophthalmologist Dr. T.S. Surendran (OP-2) shall pay Rs. 5 lakh to the parents of the deceased child (Complainants) within 6 weeks from today. Beyond 6 weeks the amount shall carry interest at 9% per annum till its realization. The OP-1 shall further pay Rs. 1 lakh towards cost of litigation. The Complaint is partly allowed.

Summary

Issues Involved:
1. Alleged gross medical negligence and deficiency in service.
2. Jurisdiction of the Consumer Commission.
3. Examination and pre-operative assessment of the patient.
4. Administration of anesthesia and related procedures.
5. Timing and dosage of pre-medication.
6. Intubation and intra-operative care.
7. Post-operative care and communication with the complainants.
8. Vicarious liability of the hospital.
9. Quantum of compensation.

Issue-wise Detailed Analysis:

1. Alleged Gross Medical Negligence and Deficiency in Service:
The complainants, parents of the deceased child, alleged gross medical negligence and deficiency in service by Sankara Nethralaya and the doctors involved, which led to the death of their child during a squint correction surgery. The surgery was advised by Dr. S. Agarkar, and conducted by Dr. T.S. Surendran (OP-2) with anesthesia administered by Dr. R. Kanan (OP-3).

2. Jurisdiction of the Consumer Commission:
The Opposite Parties (OPs) raised a preliminary objection regarding the jurisdiction, arguing that the case required extensive and elaborate evidence suitable for a Civil Court. However, the Commission proceeded with the case under the Consumer Protection Act, 1986.

3. Examination and Pre-operative Assessment of the Patient:
The child was examined by Dr. S. Sujatha, who noticed a faint systolic murmur and chest wall abnormality, and referred the child to Cardiologist Dr. S. Bhaskaran. Dr. Bhaskaran, after further examination, declared the child fit for general anesthesia without recommending additional tests like ECG, ECHO, or X-ray. The Commission found this to be a failure in the duty of care, considering the child's congenital anomalies.

4. Administration of Anesthesia and Related Procedures:
The child was administered anesthesia by Dr. R. Kanan (OP-3). Halothane was used, which is known to cause bradycardia. The child was intubated after the administration of Scoline, which further precipitated bradycardia. The Commission noted that the anesthetist failed to recognize and manage the Oculocardiac Reflex (OCR), leading to the child's cardiac arrest.

5. Timing and Dosage of Pre-medication:
The complainants argued that Atropine, used to prevent bradycardia, was not administered at the correct dose or time. The Commission noted discrepancies in the records regarding the administration of Atropine and found that the child was not properly pre-medicated, contributing to the adverse outcome.

6. Intubation and Intra-operative Care:
The Commission observed that the first attempt at intubation failed, and the second attempt, following the administration of Scoline, led to severe bradycardia and cardiac arrest. The Commission found that the anesthetist should have cautioned the surgeon about the risks associated with Scoline in pediatric cases.

7. Post-operative Care and Communication with the Complainants:
The complainants were informed about the child's death two hours after the event, which the Commission found to be a delay. The discharge summary was vague and lacked details of the resuscitation efforts. The Commission noted that the hospital delayed providing the complete medical records to the complainants.

8. Vicarious Liability of the Hospital:
The Commission held Sankara Nethralaya vicariously liable for the negligence of its doctors. The hospital, being a reputable institution, was expected to ensure due and proper care by its staff.

9. Quantum of Compensation:
The Commission awarded a total compensation of Rs. 1 Crore to the complainants, considering the gross negligence and the fact that the complainants lost their only child. The compensation was divided as follows: Rs. 85 lakh to be paid by Sankara Nethralaya (OP-1), Rs. 10 lakh by the anesthetist Dr. R. Kanan (OP-3), and Rs. 5 lakh by the operating surgeon Dr. T.S. Surendran (OP-2). Additionally, Rs. 1 lakh was awarded towards the cost of litigation. The compensation amount was to be paid within six weeks, failing which it would carry an interest of 9% per annum until realization.

Conclusion:
The complaint was partly allowed, with the Commission finding the Opposite Parties liable for medical negligence and awarding compensation to the complainants.