Most healthcare practitioners would know that they are bound to record clinical findings and not doing so amounts to medical negligence. Yet, several cases are reported on this aspect, this being one of those.
The patient had developed bed sores and was taken to Kasturi Medical Research Centre where Dr. Sircar and Dr. Adhikari performed plastic surgery – skin grafting from thigh. The patient’s condition deteriorated after the surgery and was shifted to ICU where she died after about a fortnight due to septicaemia, acute kidney injury and hypertension.
Shocked at the sudden demise and knowing in his heart that it was the doctors’ fault, the patient’s husband approached State Consumer Disputes Redressal Commission, West Bengal and laid bare facts of the case.
It was alleged that the patient was found unresponsive after the plastic surgery and was shifted to ICU, which indicated negligence on part of the doctors. While these kind of allegations are not new, the patient’s husband also made a pointed allegation – the cause of death as noted in the death certificate – septicaemia with multi-organ failure, acute kidney injury and hypertension – were nowhere noted in the medical records or prescriptions.
Moreover, as per medical record at the time of admission, the patient didn’t have kidney infection and the same developed post-operatively. What’s more, the patient’s husband concluded, that there was no mention of septicaemia also in the medical record, and these facts irrevocably proved negligence on part of the hospital and treating doctors.
Perhaps the doctors and hospital realised that they had erred, but yet tried to put best defence forward. It was stated that the patient was a known diabetic and suffered from bed sore infection from treatment taken earlier. It was further stated that injury or infection in the kidney was not at all related to the procedure that was performed, hence there was no question of negligence.
The Commission quickly explained why they were negligent by stating the following: “The prescriptions brought on record do not reveal any noting by the doctors of clinical symptoms and diagnosis by them in view of the clinical symptoms. Additionally, there is no mention of the patient suffering from septicaemia with multi-organ failure, acute kidney injury and hypertension as seen in death certificate”.
Kasturi Medical Research Centre was ordered to pay seven lakh rupees whereas Dr. Sircar and Dr. Adhikari were ordered to compensate eight lakh rupees – perhaps an expensive lesson that would remind them to appropriately maintain clinical records.
Source: Order pronounced by State Consumer Disputes Redressal Commission, West Bengal on 2nd November, 2018.