Jeewan Lal Sharma vs M/S. Serampore Surgical Nursing Private Limited

THE facts of the case are that the complainant, Shri Jeewan Lal Sharma is a businessman. He was a known diabetic, suffered Perianal abscess and took treatment from M/s Serampore Surgical Nursing Home (P) Ltd., OP 1. Dr. M. K. Roy was the attending Surgeon, OP -2. The OP 2 performed the surgery on 12.7.2008 for removal of abscess. On the same night, the patient became serious, drowsy and senseless. Therefore, the patient was transferred to Apollo Gleneagles Hospital on 13.7.2008 for treatment under Dr. Shyamasis Bandyopadhyay. The OP did not issue discharge summary or transfer certificate. The doctors of Apollo Gleneagles Hospital expressed that there was wrong treatment and that wrong operation was done by OP 2. The patient underwent two operations in Apollo Gleneagles Hospital and was discharged on 28.7.2008. The patient continued to lie in bed with regular catheter and incurred heavy medical expenses.

HENCE alleging medical negligence, the complainant filed a complaint before the State Commission, West Bengal on 5.5.2009 for total compensation Rs. 26,03,033/ -. The Commission after hearing and considering evidence on record dismissed the complaint.

WE have heard the learned counsel for both the parties. Learned counsel for the OP contended that the abscess itself was a cause of high blood sugar, it was severely painful also. The only treatment was to remove the abscess by Incision and Drainage (I & D), which will control blood sugar also. After I & D, patient developed drowsiness i.e. metabolic acidosis. For the better treatment, the patient was shifted to other hospital. The counsel for complainant submitted that, OP -2 failed to diagnose, gave wrong treatment and erroneously operated.Thus complainant spent huge sum at OP hospital as well as at Apollo Hospital. We have perused medical records from OP hospital and from the Apollo Hospital. The records reveal that the patient was admitted in OP hospital on11/7/2008, he was a known case of Diabetes Mellitus Type 2. Prior to operation, for abscess, all the necessary investigations, including cardiac evaluation was performed by OP. The clinical examination revealed wide area of induration and cellulitis, with huge perianal abscess. There was an advice slip on admission that every 8 -hourly, blood sugar estimation and injection of Insulin (Human Actrapid) as per scale (+2) were to be given. The patient was put on higher IV antibiotics, analgesics. The OP -2 has performed Incision and Drainage operation (I & D) under proper anaesthesia (saddle block).

IN view of the foregoing discussion, we are of considered view that despite every precaution, the patient developed systemic metabolic acidosis which was properly diagnosed, hence for further management OP referred patient to Apollo Hospital. Therefore we don''t find any negligence on the part of OP during treatment and during referral. It was reasonable and standard of care. Even the discharge summary of Apollo Hospital clearly revealed that the patient was a known diabetic and there was spreading of cellulitis due to perianal abscess which subsequently led to Fournier''s Gangrene. Therefore at Apollo Hospital, further treatment by Debridement of Fournier''s gangrene, perineum, scrotum with laparotomy loop sigmoid colostomy was done.

WE have perused the medical books on Surgical Management of Perianal Abscess and Fournier''s Gangrene. Fournier gangrene is a true surgical emergency. At minimum, immediate urologic or general surgical consultation is mandatory, and management often requires a multidisciplinary team, including an urologist, a general surgeon, and an intensive care specialist.

THE perianal abscess with severe cellulitis may predispose a patient to the development of Fournier gangrene, it includes Diabetes also. Occasionally, early -stage Fournier disease manifests as severe cellulitis. Treatment of Fournier gangrene involves several modalities. Surgery is necessary for definitive diagnosis and excision of necrotic tissue. Earlier surgical intervention has been associated with reduced mortality. Thus, the emergency treatment of patients with Fournier gangrene includes aggressive resuscitation in anticipation of surgery. It also provides airway management, if indicated, gives supplemental oxygen, and establishes intravenous (IV) access and continuous cardiac monitoring. Crystalloid replacement is indicated for patients who are dehydrated or displaying signs of shock.

TRANSFER to a tertiary facility may be required if these resources are not available at the initial facility. Initial debridement may be performed if required in anticipation of transfer. Transfer to a tertiary is made once the patient has been stabilized and resuscitative efforts have begun.

THEREFORE , putting reliance upon the medical text, it is clear that as a rule, the presence of an abscess is an indication for incision and drainage. Watchful waiting, while administering antibiotics is inadequate. Clinical suspicion of anorectal abscess warrants aggressive identification and surgical incision and drainage. Delaying surgical intervention results in chronic tissue destruction, fibrosis, and stricture formation and may impair anal continence. Simple perianal abscesses may be treated in the emergency department

THE judgments of Hon''ble Supreme Court and this Commission have already dealt with the issue of medical negligence. In the celebrated authority Jacob Mathew V State of Punjab & Anr, (2005) 6 SSC 1= III (2005) CPJ 9 (SC) was concluded that, " a professional may be held liable on one of two findings : either he was not possessed of requisite skill which he professed to have possessed, or, he did not exercise reasonable competence in given case, the skill which he did possess."

THE OP possesses a qualification as a Surgeon and requisite skill to treat the perianal abscess. The patient was a known diabetic, hence he developed perianal abscess, and it was necessary to treat (drain) it for immediate relief. The OP treated the patient with monitoring of blood sugar and under cover of insulin. Perianal abscess show extensive cellulitis, thus can progress to Fournier''s Gangrene. The OP referred the patient to higher centre at proper time.Referring a patient is not a case of abandonment or negligence. Although referrals generally improve the quality and care to the patients, it sometimes happens that a patient claims injury while under treatment. A doctor cannot be charged against patient abandonment if he or she refers the patient to another physician. Healthcare providers are bound by a code of ethics that states that a professional, who begins treating a patient''s illness willingly, should complete the treatment to the best of his or her ability.

THEREFORE , on the basis of foregoing discussion, we don''t find any negligence on the part of OPs. Also, we don''t see any fault with the well -reasoned order of State Commission. Accordingly, the first appeal is hereby dismissed.