2022 (11) TMI 87 - Commission - Indian Laws

Mismatched blood transfusion - mistake committed at Samad Hospital by giving B ve blood instead of O ve blood - being aggrieved by the alleged negligence, during blood transfusion and further treatment, the Complainants filed the Consumer Complaint before the State Commission, Kerala and prayed for compensation of Rs. 45 lakh with interest Rs. 4.5 lakh towards medical expenditure and Rs. 50,000/- as costs. Whether wrong blood was transfused, if yes- then whether hospital or the blood bank is liable? - HELD THAT - It was endorsed by Dr. Valentina and has also recorded in case sheet (B6), the probable cause for the transfusion reaction as mismatched blood transfusion and the resultant DIG ARF severe bleeding. It is also noted that the patient continues to be oliguric. Thus, the afore entry itself is sufficient to prove that mismatched blood was transfused to the patient. It was due to the blood bag which was kept in hospital refrigerator and transfused on the fateful day. Moreover, it was the duty of hospital to prove the wrong blood was issued from the Blood Bank, but the Appellant failed to prove it. Proper medical record has more importance. The finding of State Commission show the glaring lapses of the Opposite Parties Nos. 1 and 2, who have not kept the transfusion register showing the number of bags, its date of receipt or use or disposal. Thus, possibility of error in identification of the blood bags or identifying the patients was more. According to DW - 2 and 3 the blood transfusion was performed under the control of the duty doctor Salini and the duty nurse but there is no documentary evidence to prove their contention - it is further noted that the blood bag was kept in storage of the Hospital premise. It should be borne in mind that the cross-matched blood received from the blood bank shall be transfused within reasonable time preferably within 24 hours. However, in the instant case, there is no record that when the blood was brought from the blood bank. Therefore, it is concluded that wrong blood was transfused to the patient and the hospital staff is liable for the negligence. Whether it was a Transfusion Reaction or DIC? - HELD THAT - Admittedly, the surgery was uneventful, but within half an hour of the initiation of the transfusion, the patient suffered shivering and diagnosed it as a transfusion reaction. It is pertinent to note that the witness Dr. Valentina deposed that the transfusion blood of B ve group whereas the patient was O ve - From the details of Anaesthesia notes dated 8.8.2002 maintained by OP-3 KIMS Hospital, recorded that as - post myomectomy patient - mismatched blood transfusion - DIC Renal failure - pulmonary edema, ARDS. The aforesaid entry would make it abundantly clear that it was transfusion reaction. In most of the cases the hospital staff failing to respond to the signs and symptoms of a blood transfusion error. Thus the cause can be as simple as a breakdown in safety protocols or poor training. Though most hospitals and surgical centres have strict procedures on blood storage, but sometimes improper or poorly stored blood got issued. Reporting all transfusion-related adverse reactions to the Blood Bank promptly is more vital. Haemovigilance is the 'systematic surveillance of adverse reactions and adverse events related to transfusion' with the aim of improving transfusion safety. Transfusion reactions and adverse events should be investigated by the clinical team and hospital transfusion team and reviewed by the hospital transfusion committee. The Hon'ble Supreme Court in the case of POST GRADUATE INSTITUTE OF MEDICAL EDUCATION AND RESEARCH, CHANDIGARH VERSUS JASPAL SINGH AND ORS. 2009 (5) TMI 1011 - SUPREME COURT held that mismatch in transfusion of blood resulting in death of the patient after 40 days, a case of medical negligence - In the instant case wrong blood transfusion to Sajeena was an error which no hospital/doctor exercising ordinary care would have made. Such an error is not an error of professional judgment but in the very nature of things a sure instance of medical negligence and the hospital's breach of duty contributed to her death. Thus, there are no hesitation to hold the Opposite Party No. 1 and 2 liable for deficiency in service and the medical negligence. Compensation - HELD THAT - The Complaint was filed by 6 complainants. The patient Sajeena and her husband A.K. Nazeer were undergoing treatment for infertility at Samad Hospital, therefore A.K. Nazeer (Complainant No. 1) was the most aggrieved party. He unfortunately died in a road accident during the pendency of the complaint before the State Commission. Accordingly, his name was deleted and the parents of deceased Sajeena are Complainants Nos. 2 and 3 whereas Complainant No. 4 to 6 are the two sisters and brother of Sajeena. The parent's most stressful event in their life and cause for a major emotional crisis was that they lost their 28 years married daughter due to medical negligence and son-in-law in road accident - The Complainants stated that the deceased was earning Rs. 15000/- per month, but nothing is on record to prove her earnings. Therefore, in the ends of justice putting reliance upon the recent judgment of Hon'ble Supreme Court in ARUN KUMAR MANGLIK VERSUS CHIRAYU HEALTH AND MEDICARE PRIVATE LTD. ANR. 2019 (1) TMI 1992 - SUPREME COURT and in LATA WADHWA ORS. VERSUS STATE OF BIHAR ORS. 2001 (8) TMI 1444 - SUPREME COURT , a lump sum compensation of Rs. 20 lakh is allowed to the parents of the deceased Sajeena. The Appeal is dismissed with modification to the Order of the State Commission. The Appellants shall jointly and severally pay Rs. 20 lakh as a compensation and Rs. 1 lakh towards the cost of litigation within 6 weeks from today to the parents of deceased Sajeena. Any delay beyond 6 weeks, shall attract interest @ 7% per annum till its realization.

Summary

Issues:
- Alleged mismatched blood transfusion leading to complications
- Liability of hospital and blood bank
- Transfusion reaction or DIC determination
- Quantum of compensation for medical negligence

Analysis:
1. The case involved a married couple undergoing infertility treatment where the wife received laparoscopic surgery at a hospital. Following the surgery, a blood transfusion was ordered, leading to severe complications due to alleged mismatched blood transfusion. The State Commission partially allowed the complaint, directing the hospital to pay compensation to the complainants.

2. The hospital and doctors denied the mismatched blood transfusion, attributing the complications to unforeseen circumstances. However, the State Commission found lapses in following standard procedures post-transfusion reaction, indicating negligence on the part of the hospital and staff.

3. The key questions addressed were the confirmation of wrong blood transfusion and whether the complications were a result of a transfusion reaction or Disseminated Intravascular Coagulation (DIC). The evidence pointed towards a mismatched blood transfusion leading to severe consequences, establishing the hospital's liability for negligence.

4. The judgment emphasized the importance of proper blood transfusion protocols, including immediate response to transfusion reactions and thorough investigation of adverse events. The hospital's failure to adhere to these standards contributed to the adverse outcome in this case.

5. Referring to legal precedents, the judgment held the hospital liable for medical negligence due to the error in blood transfusion. The compensation awarded was revised to Rs. 20 lakh, considering the emotional and financial impact on the deceased's family members.

6. The judgment highlighted the significance of maintaining hemovigilance and investigating transfusion-related adverse events to enhance transfusion safety. It underlined the duty of hospitals to ensure proper blood storage, labeling, and administration to prevent errors that can have life-threatening consequences.