Case: ARUN KUMAR MANGLIK Vs. CHIRAYU HEALTH AND MEDICARE PRIVATE LTD

4. The spouse of the appellant, Madhu Manglik, was about 56 years of age, when on 14 November, 2009, she was diagnosed with dengue fever. The report of the pathological laboratory, Glaze Pathology, reported the following state of,1 gm/d/gue Ns 1 Antigen -patient was admitted to Chirayu Health & Medicare hospital at Bhopal at about 7 am on 15 November 2009. She was immediately admitted to the Intensive Care Unit. Though she was afebrile, she reported accompanying signs of dengue fever including headache, body ache and a general sense of restlessness. The patient had a prior medical history which included catheter ablation and paroxysmal supra ventricular tachycardia suggestive of cardiac complications.5. Upon admission at about 7.30 am, basic investigations were carried out. The blood report, together with the accompanying clinical examination indicated the followinglet countfor MP no malarial parasiterum bilirubin img% SGPT 521E Sodium 1404.0 meq/L Extest normal ExBp. 130/88 mmA febrile c/o Pain in2.00 pm – p-128/min, mildly– 110/70 mmthe patient was complaining of abdominal discomfort, an ultrasonography of the abdomen was carried out.6. By 6 pm, on the date of admission the patient was sinking, her blood pressure was non-recordable, extremities were cold and the pulse was non-palpable. In the meantime, the patient was placed on a regime of administering intravenous fluids. The administration of 2500ml of fluids was planned over the course of 24 hours. Between 7 am and 6 pm, she was administered about 1200 ml of fluids. The patient developed bradycardia and cardiac arrest. Faced with this situation, the treating doctors administered about 1.5 litres of extra fluids. Fluids and colloids were administered for increasing the blood pressure.7. Since the blood pressure of the patient did not improve, she was administered ionotropes (dopamine & non adrenaline). At 6.45 pm, the patient suffered a cardiac arrest. Her cardiac levels were monitored. At 6.55 pm she was examined by Dr C C Chaubey.8. Belatedly, at 7.15 pm, another blood sample was taken, which indicated the followinglet countR 10 Total protein- 3.9GOT 169At 8 pm, the patient had a cardiac arrest. She was declared dead at 8.50 pm.10. A complaint of medical negligence was instituted before the Medical Council of India.11. The Ethics Committee of the Medical Council of India came to the conclusion on 20 February 2015 that though the treating doctors had administered treatment to the patient in accordance with the established medical guidelines, the treatment was not timely. The Ethics Committee, prima facie, found that there was professional misconduct on the part of both the Director of the Hospital Dr Ajay Goenka (respondent No. 2) and Dr Abhay Tyagi. The Ethics Committee observedperusing the statements given by both the parties and documents on record in the case, the Ethics Committee discussed the matter in detailed and noted that the patient admitted in Chirayu Health & Medicare Pvt. Ltd., Malipura, Bhopal on the advice of Dr. A. Goenka but he never visited in hospital to see the patient. The committee further noted that treatment administered to the deceased in the hospital was correct as per the medical guidelines but not given timely. Although, Dr. Goenka did not went (sic)to hospital to see the patient as the patient admitted there as per his assurance and advice, therefore, the Ethics committee prima facie found that there is a professional misconduct on the part of both the doctors and decided to issue a warning to Dr. A. Goenka and Dr. Abhay Tyagi with the directions to be more careful in future while treating such type of2. This recommendation was accepted by the Executive Committee of the Medical Council. The appellate order of the Medical Council was communicated on 15 July 2015.13. The appellant instituted a complaint before the SCDRC seeking an award of compensation in the amount of Rs. 48 lakhs on the ground that his spouse suffered an untimely death due to the medical negligence of the treating doctors at the hospital.14. By its judgment dated 27 April 2015, the SCDRC came to the conclusion that a case of medical negligence was established. An amount of Rs. 6 lakhs was awarded to the appellant by way of compensation, together with interest at the rate of 9 per cent per annum.15. In appeal, these findings have been reversed by the NCDRC and in consequence, the claim stands dismissed.

Reasoning:
22. The real bone of contention in the present case is not the decision which was taken by the doctors to place the patient on a regime of intravenous fluids which, for the purposes of the present appeals, the Court ought to proceed as being on the basis of an established protocol.23. The essential aspect of the case, which bears out the charge of medical negligence, is that between 7.30 am when the patient was admitted to hospital and 6 pm when she developed cardiac arrest, the course of treatment which has been disclosed in the counter affidavit does not indicate any further monitoring of essential parameters particularly those which could be detected by a laboratory analysis of blood samples.24. Since her admission and through the day, the patient was administered intravenous fluids. The fluids were enhanced at 6 pm by 1.5 litres after she developed cardiac arrest. The record before the Court indicates that even thereafter, it was only at 7.15 pm that her blood levels were monitored. The lab report indicated a hemoglobin level of 8.1 andat 19,000. By then, the patient had developed acute signs of cardiac distress and she eventually died within a couple of hours thereafter.25. The requirement of carefully monitoring a patient in such a situation is stipulated both by the guidelines of the World Health Organisation on which the appellant has placed reliance as well as in those incorporated by the Directorate of the National Vector Borne Diseases Control Programme in 2008.26. The WHO guidelines indicate that Dengue is a ‘systemic and dynamic disease? which usually consists of three phases i.e. febrile, critical and recovery. There had been a precipitous decline in the patient?sthe day she was admitted to the hospital.The patient had a prior medical history which included catheter ablation and paroxysmal supra ventricular tachycardia suggestive of cardiac complications and thus fell in the group of patients that require in-hospital management (Group B) under WHO guidelines. The patient was evidently suffering from abdominal discomfort and hospital authorities were required to closely monitor her condition. In failing to do so in a timely manner, the respondents were unable to meet the standard of reasonable care expected of medical services.28. The issue is not whether the patient had already entered a situation involving haemorrhagic fever or a dengue shock syndrome when she was admitted on the morning of 15 November 2009. The real charge of medical negligence stems from the failure of the hospital to regularly monitor the blood parameters of the patient during the course of the day. Had this been done, there can be no manner of doubt that the hospital would have been alive to a situation that there was a decline progressively in the patient?s condition which eventually led to cardiac arrest.29. This Court has consistently held in its decisions (the decision in Kusum Sharma (supra) reiterates that principle) that the standard of care which is expected of a medical professional is the treatment which is expected of one with a reasonable degree of skill and knowledge. A medical practitioner would be liable only where the conduct falls below the standards of a reasonably competent practitioner in the field.30. Decisions of this Court elucidate on the standard of care which is expected of medical practitioners. Medical negligence jurisprudence in India is characterized by a reliance on the ‘Bolam test?.The ?Bolam test? has been the subject of academic debate and evaluation in India and other jurisdictions. Among scholars, the Bolam test has been criticized on the ground that it fails to make the distinction between the ordinary skilled doctor and the reasonably competent doctor.The former places emphasis on the standards adopted by the profession, while the latter denotes that negligence is concerned with departures from what ought to have been done in the circumstances and may be measured by reference to the hypothetical ?reasonable doctor?. The Court must determine what the reasonable doctor would have done and not the profession.Our law must take into account advances in medical science and ensure that a patient-centric approach is adopted. The standard of care as enunciated in the Bolam case must evolve in consonance with its subsequent interpretation by English and Indian Courts. Significantly, the standard adopted by the three-judge bench of this Court in Jacob Matthew includes the requirement that the course adopted by the medical professional be consistent with ?general and approved practice? and we are bound by this decision.In the practice of medicine, there could be varying approaches to treatment. There can be a genuine difference of opinion. However, while adopting a course of treatment, the medical professional must ensure that it is not unreasonable. The threshold to prove unreasonableness is set with due regard to the risks associated with medical treatment and the conditions under which medical professionals function. This is to avoid a situation where doctors resort to ‘defensive medicine? to avoid claims of negligence, often to the detriment of the patient. Hence, in a specific case where unreasonableness in professional conduct has been proven with regard to the circumstances of that case, a professional cannot escape liability for medical evidence merely by relying on a body of professional opinion.44. In the present case, the record which stares in the face of the adjudicating authority establishes that between 7.30 am and 7 pm, the critical parameters of the patient were not evaluated. The simple expedient of monitoring blood parameters was not undergone. This was in contravention of WHO guidelines as well as the guidelines prescribed by the Directorate of National Vector Borne Diseases Control Programme. It was the finding of the Medical Council of India that while treatment was administered to the patient according to these guidelines, the patient did not receive timely treatment. It had accordingly administered a warning to the respondents to be more careful in the future. In failing to provide medical treatment in accordance with medical guidelines, the respondents failed to satisfy the standard of reasonable care as laid down in the Bolam case and adopted by Indian Courts. To say that the patient or her family would have resisted a blood test, as is urged by the respondents, is merely a conjecture. Since no test was done, such an explanation cannot be accepted.45. The NCDRC had before it a well-considered judgment of the SCDRC based on the evidence on the record. While the jurisdiction of an adjudicatory authority in a first appeal is co-extensive with that of the original authority, the NCDRC has displaced the findings of fact which have been arrived at by the SCDRC without any cogent reasoning.46. The appellate authority has placed a considerable degree of reliance on the fact that the patient was on aspirin. This circumstance was drawn to the attention of the treating doctors at the time of admission. The NCDRC has merely observed that once she was admitted to the hospital, the patient was given medicines. This, in our view, is an insufficient basis to displace the findings of fact and conclusions recorded by the SCDRC.47. For the above reasons, we are of the view that the judgment of the NCDRC is unsustainable. There was no basis or justification to reverse the finding of medical negligence which was arrived at by the SCDRC.48. However, in our view, there is no basis for recording a finding of medical negligence against the Director of the hospital. The Director of the hospital was not the treating doctor or the referring doctor. Hence, while the finding of medical negligence against the hospital would stand confirmed, the second respondent would not be personally liable.49. That leads the Court to the question of damages. Finding the hospital and its Director guilty of medical negligence, the SCDRC directed compensation in the amount of Rs. 6 lakhs together with interest at 9 per cent. 50 While quantifying the compensation, the SCDRC was in error in holding that since the son and daughter of the appellant are ?highly educated and working? and had not joined as complainants, the complainant himself would be entitled to receive compensation only in the amount of Rs. 6 lakhs.51. The complainant has lost his spouse, who was 56 years of age. Though she was not employed, it is now well settled by a catena of decisions of this Court that the contribution made by a non-working spouse to the welfare of the family has an economic equivalent.52. In Lata Wadhwa v State of Bihar, (2001) 8 SCC 197  a three judge Bench of this Court computed damages to be paid to dependants of deceased persons as well as burn victims in the aftermath of a fire at the factory premises. The Court took into consideration the multifarious services rendered to the home by a home-maker and held the estimate arrived at Rs 12,000 per annum to be grossly low. It was enhanced to Rs 36,000 per annum for the age group of 34 to 59in computing compensation payable on the death of a home-maker spouse who is not employed, the Court must bear in mind that the contribution is significant and capable of being measured in monetary terms.54. In assessing the amount of compensation, we have been guided by the principle which has been laid down by the Constitution Bench in Lata Wadhwa and in National Insurance Company Ltd. v Pranay Sethi (2017) 13 SCALE 12  with suitable modifications in a case involving medical negligence.