Not making notes in medical records is medical negligence

  • Posted on: May 11, 2019

Making notes diligently and appropriately in the medical records, especially during an intervention is not just crucial from patient's safety point of view, but also for the doctor's own legal safety. In this case, the hospital and surgeon were held negligent for their failure in recording the duration of cardiac arrest suffered by the patient in operation theatre (OT), among one other critical aspect.

Memunaben was under the care of Dr. Jain who had advised hysterectomy. The procedure was performed as planned, but the outcome was something that nobody had thought of.

While hysterectomy was being performed, the patient suffered a cardiac arrest and was given CPR, but her condition deteriorated fast. She went into coma and was shifted to ICCU for better management. The patient didn't recover from coma and after about a week was transferred to another hospital where she unfortunately died.

The family was devastated and sued the hospital and the doctor for negligence. At the outset, it was alleged that the dosage of anaesthesia given was higher than normal and that was the root cause for patient suffering cardiac arrest. It was also alleged that there was no oxygen cylinder in the OT and the same was brought from another ward, this delay also contributed in deteriorating of patient's health. Lastly, it was alleged that the patient was forcefully transferred to another hospital, and these facts amount to gross negligence.

The doctor and the hospital presented facts of the case as they stated their defence. It was stated that the patient suffered a cardiac arrest as soon as an incision was made while performing hysterectomy and hence, it was decided to postpone the surgery. CPR was given immediately and the patient was managed appropriately given her serious condition.

The hospital denied the charges of lack of oxygen in the OT and stated that there was a central oxygen supply system and the same was called from another floor while the patient was being shifted to ICCU. The hospital also pointed out that the anaesthesia was administered as per proper protocol and cardiac arrest after spinal anaesthesia was a known complication.

The Commission heard both side of the story and perused medical records before delivering its ruling. It was observed that while the hospital contended that cardiac arrest after spinal anaesthesia was a known complication, little was done to prevent it. Making this observation, the Commission stated the following: 'In this case, an ECG should have been taken by the hospital to conduct a thorough pre-operative check-up of patient's condition; more so of her heart. As seen from the record, last ECG was conducted long ago. The present operation was an elective operation and was not done on emergency basis. The hospital had all the time to do thorough investigations before taking the patient to the OT. They should have assessed her cardiac status before proceeding with the operation. This failure is certainly a serious lapse on their part, knowing full well that cardiac arrest is a known complication of spinal anaesthesia'.

The Commission made another critical observation as it stated the following: 'Once cardiac arrest takes place, its management is another very important aspect in reviving the patient. Though, the operation notes speak of cardiac massage being given, perhaps referring to CPR and also 3 D.C. shocks, there is no mention in the records as to the time taken to get the heartbeat back and it is well-known that delay in reviving the patient could lead to hypoxic damage which has happened in this case. The hospital ought to have mentioned the duration of cardiac arrest, especially when the condition could not be revived neurologically'.

The hospital and the doctor both were held negligent on two counts ' first for not making appropriate pre-operative tests and secondly for not making appropriate notes in the records.

Source: Order pronounced by National Consumer Disputes Redressal Commission, New Delhi on 19th February, 2019.