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Judgment
THE present Revision Petition is being filed by the petitioner herein against the impugned final order dated 09.07.2014 in First Appeal NO. 247 of 2009 passed by the State Consumer Disputes Redressal Commission, Bihar, Patna, whereby the Ld. State Commission was pleased to dismiss the appeal filed by the petitioner with modification by disallowing the award of Rs. 50,000/ - for maintenance of the children of the respondent.
THE facts in brief are that, the complainant, Amar Kant Saran, took his wife Simple Devi, for delivery of third pregnancy to the OP Dr. Rajni Kumari. Simple Devi had history of previous two caesarian operations (LSCS). The expected date of delivery (EDD) was 25.07.2005 but, the OP doctor advised and performed her delivery at 8 am on 30.06.2005. The OP doctor informed about delivery of male child, condition of child and mother was good, but on same day, the OP did not allow the Complainant to meet his wife. On the next day, i.e. on 01.07.2005, the complainant met his wife, who was unable to talk, hence at about 7 -00 a.m., the OP advised the Complainant to take his wife to Dr. Kamini Roy at Begusarai. Hence, the complainant went outside to arrange the vehicle and on his return, the OP took few signatures of complainant, on paper. Then he approached his wife, who was found dead; by which he became unconscious. In the meantime, his wife''s body was shifted to Dr. Kamini Roy, he was not aware about when and how his wife''s body was shifted. Therefore, alleging deficiency in service and medical negligence, causing death of his wife, the complainant filed the complaint before the District Forum, Khagaria claiming compensation at the tune of Rs. 19,75,000/ - from the OP.
THE District Forum allowed the complaint and awarded Rs. 5, 00,000/ - as a compensation + Rs. 50,000/ - for maintenance of children and Rs. 15,000/ - for litigation costs. Aggrieved by the order of District Forum, the OP preferred the first appeal before the State Commission, which was dismissed with modification that direction to pay a sum of Rs. 50,000/ - on account of maintenance of children was dis -allowed.
AGGRIEVED by the order of the State Commission, the OP preferred this Revision Petition. At the admission stage, heard the learned counsel for the petitioner. The Counsel vehemently argued about the treatment given by OP doctor, it was proper as per standard norms and there was no negligence at all. She submitted that the patient approached the OP doctor on 30.06.2005 with unbearable pain, hence, immediate LSCS was performed to avoid the risks. Also, submitted that there were cordial friendly relations between deceased Simple Devi and the petitioner, as children of petitioner used to take tuition from her. It was free service, and therefore, the complainant was not consumer, hence the complaint should be dismissed.
WE have perused the evidence, the orders of the Fora below and the medical documents available on the file. The counsel also submitted that, the patient has concealed that, she was suffering from asthma. After delivery, she suffered asthmatic attack, all necessary treatment was given and the specialist doctors were called upon. On perusal of medical documents (Case sheet), it reveals that there were some irrelevant and suspicious entries. Also we could not locate clinical notes made by OP about any pre -anesthetic checkup, about the surgical procedure and the delivery of baby. The ultrasound report clearly revealed that, it was 36 weeks'' pregnancy and the foetal weight was 2807+421 gms, the EDD was 21.07.2005+ 14 days. There was one entry showing "impending to rupture" pre -LSCS. There are few post -operative (delivery) entries on 01.07.2005 at 8 -00am,12 -00am, 2.00pm, 6.00 pm, 6.30 pm and 7.00 pm, which reveal that the patient suffered from sudden onset of breathlessness and dyspnoea for which she was started with Injection Deriphyllin eight hourly, but the breathlessness went on increasing. We have noted one entry which is written in Hindi as, "Main apni marzi se rogi le ja raha hoon". It is very difficult to understand as to who wrote it and signed it ? Nothing is on record.
IT is also quite surprising to note that , the written version filed by the OP - Dr. Rajni Kumari, that the complainant was a Government teacher, who signed the risk bond (consent) after knowing the risk of operation and anesthesia, and hence, she had operated, by giving anesthesia by herself. OP submitted that the patient Simple Devi was examined by Dr. K.K. Singh, who diagnosed her as suffering from asthma and started proper treatment with oxygen and effcolin injection.
THEREFORE , on the basis of entire facts, the improper and unbelievable medical records and the available evidence on file, we are of the considered view that the OP was negligent on several counts, such as in performing LSCS operation, without proper pre -anesthetic assessment, also during post -delivery (LSCS) the patient suffered asthmatic attack, which was also not properly diagnosed and managed by the OP. There are several medical conditions like possibility of pulmonary embolism or amniotic fluid embolism which can induce breathlessness leading to death. The OP and the other Dr. K. K. Singh, failed to perform specific investigations to substantiate their diagnosis of asthma. Also, it is unacceptable to us that, during very crucial stage, the OP advised the shifting of patient to the higher centre. We don''t find any candid record from Dr. Kamini Roy Hospital (the referral hospital) about any treatment given there. Also, it is surprising that the OP herself mentioned about cordial friendly relations with the deceased Simple Devi , as children of OP used to take tuition from her. Under such circumstances, it is bereft of merit, about submission made by OP that, the patient has concealed about her asthma.
MEDICAL records have a vital role in the cases of medical negligence. An article titled "Medical records and issues in negligence" by Joseph Thomas Indian J Urol. 2009 Jul -Sep; 25(3): 384 388; the author mentioned that, It is frustrating to note that inspite of knowing the significance of proper record keeping it is still in a nascent stage in India. It is wise to keep in mind that "Poor records mean, poor defense, no records means, no defense". Medical records consist of a variety of certification of patient''s history, medical findings, diagnostic test results, preoperative proper care, function notes, post - surgical care, and daily notes of a patient''s progress and medications. An effectively acquired consent will go a long way in showing that the procedures were conducted with the concurrence of the sufferer. An effectively written operative note can secure a surgeon in case of alleged carelessness due to operative problems. It is essential that the prescribed for drugs should be readable with the name of the patient, date, and the signature of the doctor. An undated prescribed can land a doctor in trouble if the patient misuses it.
THE Medical Records are acceptable as useful evidence by court as per Section 379 of Indian Evidence Act, 1872 amended in 1961, as it is agreed that documentation of facts during the treatment of a patient is genuine and unbiased. Medical Records that are written after the discharge or hours, after death, do not have any legal value. Erasing of entries is not permitted and is questionable in court. In the event of alteration, the entire line or word should be scored off and rewritten with date, time and signature.
THEREFORE , on the basis of foregoing discussion, we do not find any apparent error in the order passed by the State Commission. Hence, the Revision Petition is dismissed