Without medical records, all efforts go in vain

  • Posted on: January 28, 2021

The patient was under antenatal care of a gynaecologist, for the delivery of her second child. The doctor performed an emergency C-section, and a premature baby was delivered. Three days after discharge, the patient was taken to the doctor with complains of abdominal pain and fever with rigors.

The doctor initially suspected malaria and prescribed medicines accordingly. But when patient’s condition did not show improvement, she was referred to a urologist. An abdominal sonography was performed which reported hydro ureter and hydronephrosis on right side along with narrowing of mid ureter along with lower ureter obscuring. In effect, the lower part of ureter on right side was ligated during C-section.

The urologist performed cystoscopy, percutaneous nephrostomy and retrograde pyelography. A few days later, ureteric implantation with Boari’s flap was performed. The patient underwent several other procedures for three subsequent months.

Once she recovered, the patient sued the gynaecologist and alleged that he failed to identify and segregate the ureter by snapping technique, which was a protocol for the procedure. It was further alleged that multiple procedures were performed and prolonged treatment was needed due to urinary tract infection, which occurred due to the doctor’s negligence.

The gynaecologist refuted the allegations and stated that there was no established protocol to identify and separate ureter during C-section. The doctor further stated that the injury was perhaps caused due to altered anatomy during the first C-section. He concluded by stating that it was rare to be injured and diagnosed late in the post-operative period.

While the Commission saw merit in doctor’s defence, he was held negligent. Observing that he did not file medical records, the Commission held that there was no evidence to show that necessary care was taken while performing C-section, and also stated the following:

“Since there is no documentation of what were the circumstances that lead to ureteric injury and whether the same was informed to patient and relatives, also what steps were taken by the doctor with anticipation of complication as well as after the complication, was the same detected early with the efforts taken by him to treat the same, no record is filed”.

“Thus, the explanation that, there was altered anatomy due to previous C-section that resulted in injuring ureter and all efforts were taken by the doctor to diagnose and treat the complication is in vain”.

Both, the gynaecologist and the hospital were ordered to compensate the patient.

Source: Order pronounced by Maharashtra State Consumer Disputes Redressal Commission on 3rd September, 2020.