DMC/DC/F.14/Comp.804/2012/
18th July, 2012
ORDER
The Delhi Medical Council through its Disciplinary Committee examined a
representation from Police Station Madhu Vihar, seeking medical opinion in
respect of death of Sheemala Devi w/o. Shri Mahesh Kumar r/o. B-28, Gali
No. 11, Zaidi Market Mandawali Fazalpur, Delhi (referred hereinafter as the
patient), allegedly due to medical negligence in the treatment administered to
late Sheemala Devi at Ram Lal Kundan Lal Orthopaedic Hospital & R.K.
Maternity Home, 8, Pandav Nagar, Opposite Mother Dairy, Patparganj Road,
Delhi and Max Super Speciality Hospital, 108 A, I.P. Extension, Opposite
Sanchar Apartments, Patparganj, Delhi, resulting in her death on 6.9.2010 at
Max Super Speciality Hospital.
The Order of the Disciplinary Committee dated 8th June, 2012 is reproduced
hereinbelow :The
Disciplinary
Committee
of
Delhi
Medical
Council
examined
a
representation from Police Station Madhu Vihar, seeking medical opinion in
respect of death of Sheemala Devi w/o. Shri Mahesh Kumar r/o. B-28, Gali
No. 11, Zaidi Market Mandawali Fazalpur, Delhi (referred hereinafter as the
patient), allegedly due to medical negligence in the treatment administered to
late Sheemala Devi at Ram Lal Kundan Lal Orthopaedic Hospital & R.K.
Maternity Home, 8, Pandav Nagar, Opposite Mother Dairy, Patparganj Road,
Delhi and Max Super Speciality Hospital, 108 A, I.P. Extension, Opposite
Sanchar Apartments, Patparganj, Delhi, resulting in her death on 6.9.2010 at
Max Super Speciality Hospital.
Contd/:
(2)
The Disciplinary Committee perused the representation from Police, joint
written statement
of Dr. Rajeev
Joshi (Surgeon),
Dr. Queen Aditya
(Gynaecologist), Dr. Preety Gautam (Anaesthetist), Dr. Viresh P. Mehta
(Physician) and Dr. A.K. Banerjee, Medical Superintendent, Ram Lal Kundal
Lal Orthopaedics Hopital & Maternity Home; statement of defence of Dr.
Queen Aditya, Consultant Gynaecology, Dr. V.K. Jain, Consultant Surgeon and
Dr. Amit Dhawan Medical Superintendent, Max Super Speciality Hospital, copy
of medical records of R.L. Kundan Lal Orthopaedics Hopital & Maternity Home,
Max Super Speciality Hospital, post-mortem report No. 718/2010 dated 9th
September, 2010 and other documents on record.
The following were heard in person. :1) Shri Mahesh Kumar
Complainant
2) Dr. A.K. Banerjee
Medical Superintendent, Ram Lal Kundan
Lal
Orthopaedic
Hospital
&
R.K.
Maternity Home
3) Dr. Queen Aditya
Consultant
Gynaecologist,
Ram
Lal
Kundan Lal Orthopaedic Hospital & R.K.
Maternity
Home
and
Max
Super
Speciality Hospital
4) D. Rajeev Johri
Consultant
Surgeon,
Ram
Lal
Kundan Lal Orthopaedic Hospital & R.K.
Maternity Home
5) Dr. Preeti Gautam
Consultant
Anaesthesia,
Ram
Lal
Kundan Lal Orthopaedic Hospital & R.K.
Maternity Home
6) Dr. Viresh P. Metha
Physician,
Ram
Lal
Kundan
Lal
Orthopaedic Hospital & R.K. Maternity
Home
Contd/:
(3)
7) Dr. Amit Dhawan
Medical Superintendent,
Max
Super
Speciality Hospital
8) Dr. V.K. Jain
Consultant
Surgeon,
Max
Super
Max
Super
Speciality Hospital,
9) Dr. Praveen
Consultant
Physician,
Speciality Hospital
Shri Mahesh Kumar, husband of the patient late Sheemala Devi stated that
in the night of 26th August, 2010, he took his wife late Sheemala Devi to
Ram Lal Kundan Lal Orthopaedic Hospital & R.K. Maternity Home, as she was
having pain in her abdomen, he deposited Rs. 5,000/-as admission charges.
He was advised operation for which he deposited Rs. 25,000/-.
He was
issued a receipt of Rs. 5,000/-. No receipt was issued for Rs. 25,000/-. He
gave his consent for the operation of his wife Smt. Sheemala Devi by putting
his signature.
He further stated that his wife’s ultrasound was done in the
early hours of 27.8.10 probably between 1.00 a.m. to 5.a.m. Shri Mahesh
Kumar denied that before getting admitted his wife to Ram Lal Kundan Lal
Orthopaedic Hospital & R.K. Maternity Home on 26.8.10 or 27.8.10 he had
taken her to Dr. Sharda in Laxmi Nagar, Delhi. He further stated that before
his wife’s admission on 26.8.10 or 27.8.10, Smt. Sheemala Devi had never
visited or consulted doctors at Ram Lal Kundan Lal Orthopaedic Hospital &
R.K. Maternity Home.
Dr. Rajeev Joshi (Surgeon), Dr. Queen Aditya (Gynaecologist), Dr. Preety
Gautam (Anaesthetist), Dr. Viresh P. Mehta (Physician) and Dr. A.K.
Banerjee, Medical Superintendent, Ram Lal Kundal Lal Orthopaedics Hopital &
Maternity Home in their joint written statement averred that the patient came
to the casualty of Ram Lal Kundal Lal Orthopaedics Hopital & Maternity Home
Contd/:
(4)
on 27th August, 2010 at 3.15 a.m. with severe diffuse pain in abdomen and
urinary retention since evening of 26th August, 2010, following dilatation and
curettage of uterus else-where on 26th August, 2010 at 3.00 p.m. as told by
the patient and the husband of the patient.
The patient’s vitals at the time
of admission were, pulse rate 130 per minute blood-pressure 140/100
afebrile. The patient was attended by gynaecologist on call and after initial
examination of the patient, a provisional diagnosis of uterine perforation and
peritonitis with septicemia was made. The surgeon and the physician on call
were informed and promptly the patient was attended by them, relevant
investigations were sent and treatment started. Seriousness of the condition
of the patient was informed to the husband and the attendants of the patient.
On ultrasound of whole abdomen free fluid was seen in the peritoneal cavity
and x-ray abdomen showed gas under diaphragm.
exploratory laparotomy was taken.
So decision of urgent
This decision was conveyed to the
patient’s husband and further high risk consent was taken for anaesthesia
and surgery. The patient’s exploratory laparotomy was done under general
anaesthesia. The findings noted on laparotomy were, haemoperetonium and
massive faecal contamination (1.5 ltr. app.); uterine perforation in upper
anterior part of uterus with ragged edges 4 c.m. long; two close by
perforations in the ileum approximately two feet from the ilio-caecal junction
were seen.
No other organ injury was seen.
The operation was done for
primary closure of the uterine perforation. Resection of the ileal segment
bearing two perforations and end to end anastomosis was done. Irrigation
and lavage of the peritoneal cavity with normal saline was done.
malecot’s drains were put in (left paracolic gutter and pelvis).
Two
Closure of
abdomen was done in layers. In post-operative period, the patient was kept
under close observation and monitoring.
The patient showed initial
improvement in terms of stabilization of heart rate. On next day the heart
rate again increased though other vitals were stable.
In view of the reContd/:
(5)
emergence of tachycardia, it was anticipated that the patient may require
intensive monitoring and management. The husband and the attendants of
the patient were informed about this and a collective decision of timely
transferring the patient to a higher centre was taken. Thus the patient was
transferred to Max Super Speciality Hospital, Patparganj, Delhi on 28th
August, 2010 in hospital ambulance.
Dr. Queen Aditya, Consultant Gynaecology, Dr. V.K. Jain, Consultant Surgeon
and Dr. Amit Dhawan, Medical Superintendent, Max Super Speciality Hospital
in their written statement maintained that the patient was admitted under Dr.
Queen Aditya at Max Super Speciality Hospital on 28th August, 2010.
The
patient was operated upon at Ram Lal Kundal Lal Orthopaedics Hospital &
Maternity Home on 27th August, 2010 for intestinal perforation and uterine
perforation allegedly caused by some doctor elsewhere on 26th August, 2010.
The patient’s exploratory laparotomy was done at Ram Lal Kundal Lal
Orthopaedics Hopital & Maternity Home by Dr. Queen Aditya and Dr. Rajiv
Johri.
Closure of duodenal perforation and resection anastomosis of small
bowel was done. The patient’s septicemia did not improve after surgery. The
patient’s pulse rate went up to 156/m and the patient was very toxic.
account
of
rising
tachycardia,
all
the
doctors
involved
in
this
On
case
cumulatively decided to shift the patient to a higher centre in case advanced
ICU facilities become necessary.
Speciality Hospital.
Hence, the patient was shifted to Max
Dr. V.K. Jain was asked by Dr. Queen Aditya to see the
case for opinion. The patient was very toxic. The patient’s pulse was 156/m.
R/R 30/m and air entry was diminished on both sides of chest. The patient
was in severe septicemia. The patient’s serious condition was explained to the
patient’s husband by Dr. V.K. Jain at 6.00 p.m. on 28th August, 2010. It was
also explained because of severe septicemia, the patient carries high risk to
her life and the patient may need ventilator anytime. The husband of the
Contd/:
(6)
patient had signed on this poor prognosis explanation and pleaded to treat in
best possible manner.
Cardiologist and physician were consulted and they
evaluated the patient from their angle. Dr. Majumdar (Anaesthetist) also
examined the patient and critical condition of the patient was explained by
Dr. Majumdar also to the patient’s husband.
CVP line was put by Dr.
Majumdar at 9.00 p.m. after seeing PT, APTT and INR report. The patient was
treated with injection cilasanin (imipenem+cilasanin combination) amikacin
and metrogyl alongwith I/V fluids and proper monitoring of CVP, B.P. Intake
output chart and continuous monitoring of vitals, SPO2 and ECG were done.
Since, it was operated case of perforation peritonitis and was operated upon
by qualified surgeon and gynaecologist only one day before, it was logically
presumed that it is a case of septicemia. The patient’s TLC was also low
(3900) suggesting severe septicemia.
CECT with oral contrast was not
advised on second day of anastomosis because of fear of leak.
ultrasound whole abdomen was done.
However,
It showed only minimal inter-loop
fluid. The patient also had severe hypoalbumenemia (alb 1.7 gm% only). In
subsequent two-three days, the patient showed good improvement.
The
patient’s pulse rate gradually came down to 136/min. and respiratory rate to
17/min. on 29th August, 2010 and air entry also improved on both side. The
patient’s abdominal drains also revealed only (50 ml Rt and 10 ml Lt.) small
haemorrhagic fluid on 29th August, 2010 at the morning.
There was no
evidence of any faecal fluid in drains. On 29th August, 2010 at the evening,
fluid was only 10 ml. On 30th August, 2010, the patient became much better.
The patient’s pulse came to 112/min. and tube drain was nil but sill the
patient was looking very toxic. The patient passed flatus on 30th August, 2010
at the evening. But, the patient’s TLC diminished further to 2500 suggesting
persistent septicemia. The patient passed flatus two-three times and her HB
also dropped because of septicemia (7.8gm%). Adequate blood transfusion
and physiotherapy were given.
In view of persistent septicemia, injection
Contd/:
(7)
Targocid was also added on 1st September, 2010.
Since recovery was not
satisfactory and moreover, the patient looked more drowsy and toxic on 1st
September, 2010, CECT whole abdomen and chest were advised to rule out
any large pus pocket in abdomen.
Rectal contrast was also given.
CECT
revealed large leak of contrast from sigmoid colon. On identification of this
leak which most probably had occurred on 1st September, 2010, the patient
was immediately taken up for laparotomy. On exploration multiple inter-loop
collection of pus were found. Faecal matter was found in left lower abdomen
and lower sigmoid colon found to be completely transected. Its margins were
irregular. It appeared that as if it was crushed by some instrument at the
time of D&C and uterine perforation but could not be detected in first surgery
because
its
continuity
was
maintained.
On
4th
post-operative
day
crushedportion might have given way and leaked leading to deterioration of
condition again. During surgery colon was mobilized and end to end
anastomosis done.
All pus pockets opened and pus removed.
Protective
ilestomy done in right iliac fossa. Post-operatively, the patient had persistent
fever and septicemia. The patient continued to be on ventilator. Critical care
specialist, physician and cardiologist continue to see the patient as and when
required. Before 2nd surgery (1st at Max), the patient’s husband was clearly
explained that the patient may die on table or after the operation because of
severe septicemia and husband of the patient accepted all the responsibility
and consequences. The patient kept on deteriorating post-operatively inspite
of best efforts by all the doctors involved in treatment.
Pus from abdomen
revealed E-coli on culture sensitivity that was sensitive to amikacin and
cilanem.
These antibiotics were already being administered. The patient’s
ileostomy was working well.
Wound did not reveal any significant sepsis.
Repeat ultrasound on 4th September, 2010 showed mild inter-loop collection
of fluids. Wound swab culture again showed E-coli sensitive to ertapenem.
Ertapenem and clindamycin were given. The patient did not improve and
Contd/:
(8)
kept on deteriorating.
The patient continued to have very high grade fever.
It was not controllable with cold sponging and antipyretic drugs.
Severe
tachycardia up to 160-170/min. also remained for long time. The patient had
sudden cardiac arrest at 5.45 a.m. on 6th September, 2010. All resuscitative
measures carried out but the patient could not be revived and declared dead
at 6.15 a.m. on 6th September, 2010.
It was further averred that the patient’s sepsis started on 26th August, 2010
because the patient’s D&C was done by some unqualified doctor. The doctor
must have used unsterilized instruments that caused perforation of uterus
and intestines. The patient remained at home for more than twelve hours
with this potentially fatal peritonitis. Crushed portion of sigmoid colon gave
way on 1st September, 2010 leading to further deterioration. Septicemia could
not be controlled inspite of sincere efforts done by all the doctors concerned
and the patient died of speticemic shock. The patient was thus probably mismanaged at the time of MTP/D&C and went into septicemia. The patient was
explored at another hospital and then finally sent to Max Super Speciality
Hospital for management of existing complications. Inspite of best possible
management, the patient succumbed to her (the patient) complications of
MTP/D&C.
Thus it cannot even be remotely imagined how at Max Super
Speciality Hospital or its doctors were involved in medical negligence.
The
doctors were only trying to battle with an existing complication with which the
patient presented. It is clear that the patient was provided the best possible
medical treatment, as per accepted protocols. It is also abundantly clear that
there was not even an error of judgment; leave aside medical negligence, on
the part of team of treating doctors and para-medical staff at the hospital.
The Disciplinary Committee noted that the S.H.O. Police Station Madhu Vihar
vide a communication dated 4th February, 2011 informed that Shri Mahesh
Kumar husband of late Sheemla Devi was contacted to provide the details of
Contd/:
(9)
D&C procedure who gave in writing that it was done at Ram Lal Kundan Lal
Orthopaedic
Hospital
&
R.K.
Maternity
Home;
whereas
the
Medical
Superintendent, Ram Lal Kundan Lal Orthopaedic Hospital & R.K. Maternity
Home denied the same.
It is further noted that as per the post-mortem report NO. 718/2010 of Late
Sheemla Devi, the cause of death was “shock due to peritonitis and
septicemia following rupture of uterus and bowel perforation caused by
instrumentation performed on the deceased”.
In light of the above the Disciplinary Committee make the following
observations :1. As per the records of Ram Lal Kundan Lal Orthopaedic Hospital & R.K.
Maternity
Home, the patient reported
to Ram Lal Kundan
Lal
Orthopaedic Hospital & R.K. Maternity Home on 27th August, 2010 at
4.00 a.m. with complaint of retention of urine, pain lower abdomen.
She had history of having undergone D&C on 26th August, 2010 at
some private clinic (Dr. Sharda, Laxmi Nagar, Delhi). The patient was
diagnosed
diaphragm.
to
have
perforation
peritonitis
with
free
gas
under
She was operated upon on 27th August, 2010 for
laparotomy by Dr. Queen Aditya (Gynaecologist) and Dr. Rajeev Johri
(Surgeon).
Uterine
perforation
was
anaestomosis of small bowel was done.
repaired
and
resection
However, the patient was
found to be very toxic and had septicemia with pulse rate of 150/min,
hence, the patient was shifted to Max Super Speciality Hospital by Dr.
Queen Aditya on 28th August, 2010. At Max Super Speciality Hospital,
Dr. V.K. Jain (Surgeon) was consulted for opinion.
The patient’s
condition did improve little bit for two days with high antibiotic cover
and proper ICU care but deteriorated again on third day. CECT whole
Contd/:
(10)
abdomen done on 1st September, 2010 revealed large leak in sigmoid
colon.
The patient was taken up for laparotomy and whole sigmoid
colon found to be transected.
ileostomy was done.
Repair of sigmoid colon and diverting
The patient remained on ventilator post-
operatively.
The patient had persistent high temprative and severe
tachycardia.
Inspite of treatment, the patient’s condition kept on
deteriorating. The patient had severe septic shock. The patient died
on 6th September, 2010 at 6.15 a.m.
The Disciplinary Committee observes that the patient was treated at
Ram Lal Kundan Lal Orthopaedic Hospital & R.K. Maternity Home as per
accepted professional practices in such cases.
The patient who had
developed complication of D&C procedure conducted on 26th August,
2010, which manifested in the form of uterine perforation and
septicemia was rightly operated for repair of uterine perforation and
resection anaestomosis of small bowel.
The patient, however, was
found to be toxic with septicemia and hence was shifted to Max Super
Speciality Hospital.
At Max Super Speciality Hospital, the patient’s
condition continued to remain serious and inspite of undergoing surgical
procedure of repair of sigmoid colon with diverting ileostomy, high
antibiotic cover and ventilatory support; she went into severe septic
shock and expired.
2. The complication which the patient developed and which led to her
death was due to the negligent manner in which the D&C procedure
was conducted.
In light of the denial of Medical Superintendent, Ram Lal Kundan Lal
Orthopaedic Hospital & R.K. Maternity Home that D&C procedure was
Contd/:
(11)
conducted at the Ram Lal Kundan Lal Orthopaedic Hospital & R.K.
Maternity Home which is supported by the documents/records of the
Ram Lal Kundan Lal Orthopaedic Hospital & R.K. Maternity Home, the
police
needs
to
investigate
and
identify
the
person
or
the
centre/hospital where D&C procedure was conducted on late Sheemla
Devi on 26th August, 2010, prior to admission to Ram Lal Kundan Lal
Orthopaedic Hospital & R.K. Maternity Home, so as to fix the liability of
the negligence committed.
In light of the observations made hereinabove, it is, therefore, the decision of
the Disciplinary Committee that no medical negligence can be attributed on
the part of doctors at Ram Lal Kundan Lal Orthopaedic Hospital & R.K.
Maternity Home and Max Super Speciality Hospital, Patparganj, Delhi, in the
treatment administered by them, to late Sheemla Devi.
Matter stands disposed.
Sd/(Dr. O.P. Kalra)
Chairman
Disciplinary Committee
Sd/-
Sd/-
(Dr. Prem Aggarwal)
(Dr. Vijay Zutshi)
Eminent Publicman
Expert Member
Member
Disciplinary Committee
Disciplinary Committee
Sd/(Dr. R.S. Mohil)
Expert Member
Disciplinary Committee
Contd/:
(12)
The Order of the Disciplinary Committee dated 8th June, 2012 was
confirmed by Delhi Medical Council in its meeting held on 4th July, 2012.
By the Order & in the name of
Delhi Medical Council
Copy to :-
(Dr. GirishTyagi)
Secretary
1) Shri Mahesh Kumar, r/o, B-28, Gali No. 11, Zaidi Market, Mandawali
Fazalpur, Delhi-110092
2) Medical Superintendent, Ram Lal Kundan Lal Orthopaedic Hospital &
R.K. Maternity Home, Bunglow Plot No. 8, Pandav Nagar, Patparganj
Road, Delhi – 110092
3) Medical Superintendent, Max Balaji Hospital, 108A, Indraprastha
Extension, Patparganj, New Delhi-110092
4) SHO, Police Station Madhu Vihar, New Delhi – 110092 – for
information
5) Inspector Anand Kumar, I.O. , Police Station Madhu Vihar, East District,
New Delhi - 110092 – for information
(Dr. GirishTyagi)
Secretary