No medical records? No legal defence!

  • Posted on: March 09, 2021

The patient’s right hand was fractured in a small accident. The orthopaedic surgeon performed a minor surgery to insert k-wire and applied plaster. The patient continued to experience pain even five months after the procedure, and hence visited another orthopaedic specialist who opined that elbow injury was missed by the earlier doctor and the radiologist.

This matter reached Consumer Commission. The patient alleged that the first doctor missed the elbow injury due to which she was partly incapacitated and lost her job.

The doctor denied the allegation and stated that the patients elbow movement range was 90 to 0 degrees when she had come for follow up after five months. This clearly proved that there was good movement of the elbow, contrary to patient’s claims.

The Commission went through the medical records and disagreed with the orthopaedic surgeon. At the outset, it was observed that while the doctor mentioned ‘minor elbow dislocation was corrected under anaesthesia’ in his written statement, nothing was noted in the discharge summary or indoor papers. The Commission stated that “anything just mentioned in written statement without corroborating evidence in the indoor case record cannot be considered”.

The Commission also took into account of opinion of an expert who stated that the joints above and below the injured limb must be X-ray’d to confirm whether there is any dislocation or not. It was observed that the orthopaedic surgeon had not followed this protocol, hence he was held negligent.

Source: Order pronounced by Andhra Pradesh State Consumer Disputes Redressal Commission, on 19th August, 2020.