The patient was admitted to a hospital with agonizing ano-rectal pain and high-grade fever since four days. Evidently, there was some infection and the pus had to be drained from the infected region.
General anaesthesia was administered and incision & drainage (I&D) was performed. Post-operatively, the patient was kept in ICU for observation.
After about six hours, the patient developed septicaemic shock and hence, he was shifted to a higher centre. The complications subsided and the patient recovered only after visiting three to four other hospitals.
The hospital and surgeon who performed I&D were sued. It was alleged that the doctor negligently performed the procedure, and the hospital did not provide medical records, surgical notes, etc. at the time of transfer to higher centre.
While the hospital narrated the entire episode and presented details about how the patient was appropriately managed and transferred without any delay, a startling statement was also made – ‘medical reports were not prepared as it was a minor procedure’.
The Consumer Commission, was surprised or so it seemed from the following observations:
“Strange explanation given by the hospital that case sheet was not prepared and no entries were made in the ICU register about surgery as it was done in emergency though the patient was in ICU for six hours”.
“Medical records not only serve as necessary documents for apt patient management, but they are also legal documents. These records contain useful evidence for diverse litigations including personal injury cases, criminal cases, workers’ compensation, disability determinations, and medical negligence claims. It should be borne in mind that Good Record is Good Défense and Poor Record is Poor Défense and No record is No Défense”.
The case against doctor was dismissed but the hospital was held negligent and ordered to pay nearly six and a half lakh rupees!
Source : Order pronounced by National Consumer Disputes Redressal Commission on 9th January, 2023.