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Judgment
Dr. S.M. Kantikar, Presiding Member
The Present Complaint has been filed under section 21 (a) (i) of the Consumer Protection Act, 1986 (for short “the Act”) by Suresh Chandra Parekh (hereinafter referred to as the ‘Complainant’) against Dr. Naresh Trehan & Medanta, The Medicity (hereinafter referred to as the ‘Opposite Parties’) seeking compensation to the tune of Rs. 2,25,68,000/-
On 31.03.2014 The Complainant Suresh Chandra Parekh, aged 74 years visited Medanta Hospital (OP-2) with problems of Angina & heaviness in chest. He was admitted on next day i.e. 01.04.2014 and Coronary Angiography (CAG) was done. It revealed “Native Triple Vessel Disease (TVD)” consisting of LAD having 100% Blockage, LCX as Dominant vessel having Two Blockages-80 % & 50%. Thereafter, Dr. Trehan (OP-1) advised the Complainant for “Bypass Surgery” and told that he would perform the surgery. Accordingly, on 07.04.2014 surgery was performed by OP-1. It was alleged that only one blockage (LAD) was By-passed and the remaining two blockages (LCX) were left untouched. It was further alleged that OP-1 never informed the Complainant about one vessel by-pass instead of three, neither before nor after the surgery. After removal of stiches on 21.04.2014, he was permitted to travel back to his home town at Bhopal. On 24.04.2014, the Complainant felt breathlessness and was admitted to Akshay Hospital, Bhopal. There, the doctors opined that it could be due to after effect of surgery. Since the problem continued, the Complainant went to OP-2 on 11.06.2014 and some tests were conducted. Everything was found good. Subsequently, again on 17.06.2014 night, the Complainant felt breathlessness and heaviness in chest and was admitted to Bansal Hospital, Bhopal. The doctors informed him that he suffered heart attack. Thereafter, due to repeated problem of breathlessness Angiography was done on 05.07.2014 at Bansal Hospital which revealed two blockages 100% and 75%. An emergency Angioplasty was performed and two stents were inserted. The Complainant was discharged on 08.07.2014.
Being aggrieved due to the gross negligence and deficiency in service by the Opposite Parties, the Complainant filed the Consumer Compliant under section 21 of the Consumer Protection Act, 1986 before this Commission and prayed compensation amounting to Rs. 2,25,68,000/- from the Opposite Parties.
The Opposite Parties filed their Written Version denying the allegations of medical negligence. It was submitted that the Complaint was filed without complete medical record and the CD of angiography conducted at Bansal Hospital. Therefore, it was difficult to ascertain the actual disease progression and the medical treatment received by the Complainant at other places after discharge from OP-2. The Complainant has claimed an exaggerated compensation to bring the Complainant within pecuniary jurisdiction of this Commission. The patient received the highest standard of care, expertise and post-operative care from the OPs, with reasonable skill and competence in the interest of the Complainant. The OPs filed entire medical record.
Heard the arguments through hybrid mode. The Complainant argued in person through video-conferencing and the learned Senior Counsel for the OPs argued the matter physically. They have reiterated the facts and their evidence. Perused the material on record, inter alia, the Medical Record and gave thoughtful consideration. Both the sides have reiterated their evidence and placed the medical literature and AHA guidelines.
It is pertinent to note that the Complainant was a known case and under treatment of Coronary Artery Disease (CAD). He was hypertensive (since 1990) and post CABG (in year 1983) and post Percutaneous Transluminal Coronary Angioplasty (PTCA). He was a reformed tobacco abuser and consumes alcohol occasionally. On 31.03.2014, at 6.45 pm, the Complainant was seen by the Cardiologist - Dr. R.R. Kasliwal. Clinically, the patient showed signs of angina, the investigations were normal, therefore he was advised to undergo Coronary Angiography (CAG) and 2D ECHO. The 2D ECHO was done outside it, revealed severe Left Ventricular Hypertrophy (LVH) and Ejection Fraction (EF) to be 60%. A fresh bedside 2D ECHO was conducted to reconfirm the findings. It revealed LVEF dropped to 45-50% from 60%. At 01.20 PM, CAG was conducted and reported as Native Triple Vessel Disease. The findings revealed the Complainant had significant LAD 100% occlusion. However, osteal plugging or the disease in LCX and RCA vessels was not significant and could be managed medically.
It is pertinent to note that from CAG findings, the contemplated line of treatment was bypass only one vessel - LAD. No intervention was planned for LCX and RCA. It was discussed in detail with the Complainant and family members. At 12.45 PM, the Complainant was also explained about the Redo (CABG) and told about possible outcome related to recovery, risks and complications. Therefore, a high risk informed consent in view of redo CABG surgery was given by the Complainant.
On careful perusal of chronology of events , on07.04.2014, CABG surgery was conducted by the Cardiac Surgery team led by Dr. Naresh Trehan. The surgery was uneventful. The GAG findings were reconfirmed intraoperatively, wherein only LAD was found to be graftable and LCX and RCA were found to have an insignificant blockage not requiring CABG and/or PTCA. The post-CABG cardiac Doppler revealed normal findings. Post operatively, the Complainant's heart rate was 97/min and SP02 was 100%. He was afebrile, cardiac output/ cardiac index was noted to be 4.76/2.98. The Complainant was discharged on 13.04.2014 with medication advice.
On 12.06.2014, the Complainant underwent a comprehensive health check up at the OP-2 Hospital and found normal. There was no arrhythmia or no fresh changes from the last ECG. The Stress ECHO was negative for inducible myocardial ischemia. Urine and Blood analysis and lipid profile also revealed normal findings.
The medical record clearly establishes that the surgical team took a decision that the RCA was not clinically graftable and as no osteal plugging or no significant LCX disease, the LCX graft was not needed, the intervention was not done. However, the LCX blockage progressed rapidly, which required 2 stents. The comparison of the LCX block was noted as below:
LCX vessel Parameters
01.04.2014
05.07.2014
Osital
Plaquing
Not mentioned
Proximal
Not mentioned
75% lesion
Mid
50% stenosis
Not mentioned
Distal
80% stenosis
100% lesion
As per the American Heart Association (AHA) Practice Guidelines that CABG or PCI to improve symptoms should not he performed in patients who do not meet anatomic (>50% left main or >70% non-left main stenosis) or physiological (e.g. abnormal fraction flow reserve) criteria for revascularization. In the discharge summary of the instant case, it has been mentioned that the procedure conducted on 07.04.2014 was REDO OPCAB XI GRAM (RSVG TO LAD)
I have perused the final report of Board of Medical Expert from AIIMS dated 13.02.2022, It was held under chairmanship of Dr. S. K. Choudhary, Prof. & Head, CTVS Department.
12.1 The board has located two major grievances of the patient:-
12.1.1 Grievance-A:.The treatment carried out at Medanta Hospital was incomplete. The circumflex artery was not dealt with adequately. As a result the patient has to suffered and had undergo another procedure
· As per the review of Coronary Angiography study carried out at Medanta Hospital on 01.04.2014, it revealed following findings:
· A large sized LAD (Left Anterior Descending) artery. The left anterior descending artery (LAD) wraps around the cardiac apex into the posterior interventricular groove (type III). It had 100% ostial occlusion. Suitable for grafting.
· Left Circumflex artery: Mid-segment 50% and distal 75% obstruction. OMI: Moderate size, normal. OM2: Small, normal. OM3,4: Very small. No graftable OM beyond distal lesion in Circumflex artery.
· The PD(posterior descending) artery coming from the Left Circumflex artery is small in caliber. It supplies to a small area of Left Ventricular myocardium. Questionable graftability.
· RCA is small, nondominant, with nearly 60% lesion. Non-graftable.
· The previous vein graft to LAD: Blocked at origin. Nearly 70% obstruction at anastomosis.
12.1.1.1 Assessment of effects of ischemia
· Echocardiography showed akinetic mid posterior wall, basal IVS, and basal inferior wall.
· SPECT myocardial perfusion scan showed stress induced ischemia involving large (15-20 % area) apical segment and adjacent inferolateral wall.
It opined that those findings suggest that ischemia was predominantly limited to LAD territory.
12.1.1.2 Assessment of adequacy of the surgical procedure
· In post-operative period, though the patient had chest discomfort and breathlessness, his Exercise Stress Echocardiography was negative for any inducible ischemia. This means, in post-operative period, there was no ischemic segment of myocardium requiring intervention. In pre-operative period, SPECT myocardial perfusion scan showed stress induced ischemia involving large (15-20 % area apical segment and adjacent inferolateral wall. In post-operative period, Exercise stress echocardiography could not demonstrate any stress induced ischemia.
12.2 Grievance B:
The Committee observed that;
A standard consent has been taken. There is no mention of number of grafts. Usually, the number of grafts is not mentioned in the consent form. Very often, the information exchanged between the surgical team and the patient is much more than the actual written consent. The Committee has no data about the actual consent process. Hence, the Committee is not in a position to comment upon the consent process.
12.3 The Committee, in its final opinion, held that the treatment provided at Medanta Hospital was optimal and reasonable. In my view, the mode of treatment and procedure adopted by the OP was as per the standard of practice.
Reliance is put on the catena of judgments of Hon’ble Supreme Court which defined the medical negligence. In the case of Jacob Mathew Vs. State of Punjab & Anr.[ (2005) 6 SSC 1], it was held that;
“no sensible professional would intentionally commit an act or omission which would result in harm or injury to the patient since the professional reputation of the professional would be at stake”.
In the case of S. K. Jhunjhunwala vs. Dhanwanti Kaur and Another[(2019) 2 SCC 282] it was held that in every case where the treatment is not successful or the patient dies during surgery, it cannot be automatically assumed that the medical professional was negligent.
Recently the Hon’ble Kerala High Court in Philips Thomas v. State of Kerala case[2023 SCC OnLine Ker 686, decided on 02-02-2023] held that “When things go wrong, it is not always the doctor’s fault”. The High Court acquits medical staff in negligence case.
Based on afore discussion, the opinion of the board of experts from AIIMS and law laid down by Hon’ble Apex Court, in my view, the Complainant failed to prove negligence of the OPs. The medical negligence is not conclusively attributable to the OPs.
The Complaint is dismissed.
The Parties to bear their own costs.