Unsigned documentation – Surgeon held negligent, pays compensation

  • Posted on: April 18, 2024

This is an interesting case. A surgeon was sued by the patient, who had alleged that the doctor had operated to remove kidney stone; but it was later discovered that it was not removed. Therefore, another operation had to be performed elsewhere to remove it.

The surgeon presented a defiant stance. It was stated that no operation was performed; the patient was only clinically managed during his stay at the hospital.

The doctor pointed out that the patient ‘eloped’ from the hospital and took the treatment chart, among other papers, kept on a pad hanging at the bedside. But he returned after few days to seek medical treatment, and on compassionate grounds the treatment was resumed.

The doctor submitted prescriptions, which were admittedly unsigned, to prove that no operation was performed. However, when questioned about the discharge summary, the doctor denied that it was issued by the hospital as it was unsigned by any doctor!

The Commission went through the papers and found loopholes in the surgeon’s defence. The Commission observed: 

There is a paper in which it has been written that the operation was performed and stone was removed under spinal anaesthesia. The surgeon has admitted two prescriptions in which there is no signature which shows that he did not sign any prescription. Therefore, it may be presumed that he did not sign the discharge summary either.

The surgeon was held negligent and ordered to pay one lakh rupees compensation.

Source : Order pronounced by Uttar Pradesh State Consumer Disputes Redressal Commission on 13th March, 2024.