| STATE CONSUMER DISPUTES REDRESSAL COMMISSION |
| WEST BENGAL |
| 11A, Mirza Ghalib Street, Kolkata - 700087 |
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| BEFORE: | |
| HON'BLE MR. JUSTICE MANOJIT MANDAL PRESIDENT | |
| HON'BLE MRS. SAMIKSHA BHATTACHARYA MEMBER | |
| HON'BLE MR. SHYAMAL KUMAR GHOSH MEMBER |
| PRESENT: | In-person/, Advocate for the Complainant 1 |
| Soumen Mondal, Advocate for the Opp. Party 1 |
| Final Order / Judgement |
MR SHYAMAL KUMAR GHOSH, MEMBER 1. The instant consumer case relating to medical negligence has been instituted by the complainant viz. Sri Prosenjit Roy Chowdhury against the opposite party/Green View Nursing Home praying for compensation, costs etc. 2. The factual matrix of the case is that the complainant’s wife viz. Smt. Panchali Roy Chowdhury was admitted at the op/hospital on 25/12/2014. The bed no. 3, at the female ward of the aforesaid nursing home, was allotted for said patient. She gave birth to a female child on that night. 3. On 26/12/2014 at about 1 AM the complainant was informed about huge bleeding of the patient. The complainant reached the op/nursing home immediately. The nursing home authority asked for bringing 2 packets of blood (A+ group). The BP of the patient was gradually increased. 4. However, as per instruction of the op/nursing home authority the complainant collected the blood and submitted the same at the office of op/nursing home on that night. 5. At about 4 AM the op/nursing home informed the complainant that the condition of the patient was little better. It was also informed that the op/nursing home would start blood transfusion next morning. 6. On 26/12/2014 morning the blood transfusion was started. At about 8 AM the complainant checked that the blood (A+) had been transfusing to the patient. 7. At 4 PM (visiting hours) on 26/12/2014 the complainant visited the bed no . 3 of female ward wherein he found that wrong blood (B+ group) had been transfusing to the patient instead of blood (A+). The patient was feeling cold and as such she was covered with 4 blankets. The matter was informed to the op/nursing home authority but to no effect. 8. The complainant felt very helpless. No attendant was available. No RMO was available. Having no other alternatives the complainant called for his friend who was a doctor in order to meet up the aforesaid crisis. The said friend-doctor reached at the op/nursing home within half an hour. In the mean time the op/nursing home authority removed the wrong packet of blood. After reaching of his friend cum doctor, Dr. S. Saha, RMO came and consulted with him and thereafter the op/nursing home applied for some medicines to the patient. But the said medicines were not noted down in the prescription sheet. 9. The op/nursing home authority made repeated blood test during that period. Some reports were given to the complainant but some were suppressed. 10. The matter was informed to his appointed Dr viz. Dr K.R. Saha. Surprisingly the op/nursing home authority was extremely casual to him and was more interested to contact with Dr. A.K. Ghosh who is a panel doctor of said nursing home and surgeon who operated the complainant’s wife. 11. To that effect number of letter was written down addressed to the op/nursing home but said authority did not bother to reply the same. 12. The event was informed to the CA & FBP Department but the disputes between the parties were not solved. 13. There is clear gross negligence and fault on the part of the op/nursing home. Having no other alternatives, the complainant rushed to this Commission in order to get proper relief/reliefs as prayed for against the Opposite Party/Nursing Home. 14. The opposite party/nursing home contested this case by filing written version stating inter alia that the complainant has not made the treating doctors attached to the op/nursing home as parties to the case. The complainant has not impleaded his friend Dr. S. Saha as a party to the instant consumer case. The instant application is barred by law of limitation. The complainant suppressed the material facts. The petition of complaint does not corroborate with the evidence filed by the complainant. Actually the complainant submitted a new story in his evidence. By filing written version it is stated that without any medical expert report, the dispute cannot be settled. 15. By filing written version the opposite party/ nursing home admitted that the patient viz. Panchali Roy Chowdhury, aged about 36 years, was admitted at the op/nursing home on 25/12/2014 at about 11.50 AM as a case of 2nd Gr. Pregnancy under care of Dr. K.R.Saha. On the said date at about 8 PM LUCS was done by Dr. A.K. Ghosh. 16. The opposite party submitted that the blood transfusion procedure was uneventful, no post operative complication arose. Regarding wrong blood transfusion, the complainant failed to prove his case by filing evidence on affidavit. 17. By filing written version the op/nursing home submitted that at about 1 AM in the post operative period on 26/12/2014 patient was passing excessive blood per vagina. The RMO informed the operating doctor A.K. Ghosh regarding said event. As per doctor’s advice, the nursing home authority asked for bringing 2 units of blood A+ as early as possible. The patient party brought aforesaid 2 units blood in early morning. The op/nursing home authority started blood transfusion at 7 AM and another bottle was started at about 12 noon on the same day. After transfusion of blood, the patient had no complication and abnormality. Subsequently the patient was discharged on 29/12/2014 with good condition. Discharge certificate of the patient was given to the patient party wherein all treatment procedures and further advice were clearly mentioned. So there is no question of wrong blood transfusion to the patient. 18. By filing written version the op/nursing home stated that all papers including BHT were already handed over to the complainant at the time of discharge of the patient. Some documents were enclosed in the petition of complaint on filing. 19. The complainant has filed his evidence on behalf of his wife without any letter of authority. There is no fault or deficiency in service on the part of op/nursing home and accordingly the petition of complaint is liable to be dismissed with exemplary costs. 20. At the time of final hearing the complainant in person has argued that the wrong blood was transfused to the patient. The patient actually needed A+ blood. But instead of applying A+ blood, the patient received the blood of B+ group. There was every chance to cause any fatal to the patient and such type of omission or commission on the part of op/nursing home clearly causes gross negligence or fault on the part of the op/nursing home. To that effect the complainant drew our attention by showing the prescription dated 26/12/2014 wherein it is evident that mismatched blood transfusion was occurred. The complainant in person has also argued that on 09/02/2015 and 12/03/2015 the complainant wrote two letters addressed to the op/nursing home requesting for supplying some documents. But unfortunately those documents were not supplied to the complainant. However, the BHT was given to the complainant but there was no such endorsement at the back side of said document. Accordingly the complainant in person has prayed for compensation and cost on the ground of fault or negligence from the end of op/nursing home. 21. Ld advocate appearing for the opposite party/nursing home has urged that there is no such evidence from the complainant wherein it would be proved that the event of wrong blood transfusion was occurred. Rather the patient was correctly and properly treated at the op/nursing home. There was no such wrong from the end of op/nursing home. After discharge from the op/nursing home, there was no such complication of the patient. The ld advocate clearly denied to provide 4 numbers of blanket to the patient. The ld advocate cited a medical journal viz Davidson’s Principles & Practice of Medicine and submitted that death directly attributable to transfusion is very rare. Some symptoms of transfusion reactions such as fever, itch, chills, respiratory distress etc may be occurred. But there is no chance to cause death of patient. At the time of final hearing ld advocate argued on the point of postanesthetic shivering which means shivering after anesthesia. It is one of the leading causes of discomfort in patients recovering from general anesthesia. Actually it is the intention to grab some money as compensation from the op/nursing home which is very illegal and baseless. The petition of complaint does not corroborate with the evidence adduced by the complainant. In evidence, the complainant mentioned some new story which is certainly frivolous and vexatious and accordingly the petition of complaint is liable to be dismissed with exemplary costs. 22. We have heard the complainant in person and ld advocate appearing for the opposite party at length and in full. 23. We have considered the submissions of both sides. 24. We have meticulously perused all materials available on record. 25. The final hearing was concluded. 26. It is admitted that the patient viz. Panchali Roy chowdhury aged about 36 years was admitted at the op/Green View Nursing Home on 25/12/2014 at 11.50 AM for 2nd Gr. Pregnancy and discharged from the said nursing home on 29/12/2014 at about 10 AM. Some advices were given to the patient/mother as well as baby and the whole facts are clearly revealed from the discharge certificate issued by the op/nursing home. Be it mentioned here that the said discharge certificate does not bear any date. 27. The patient was admitted under care of Dr. K.R. Saha and on 25/12/2014 at 8.00 PM LUCS was done by Dr. A.K. Ghosh attached to the op/nursing home which is clearly revealed from the bed head ticket issued by the op/nursing home. 28. In pursuant to the written version filed by the op/nursing home it is admitted that at about 1 AM in the post operative period on 26/12/2014 patient was passing excessive blood per vagina. The RMO informed the operating doctor A.K. Ghosh regarding said event. As per doctor’s advice, the nursing home authority asked for bringing 2 units of blood A+ as early as possible. The patient party brought aforesaid 2 units blood in early morning. The op/nursing home authority started blood transfusion at 7 AM and another bottle was started at about 12 noon on the same day. 29. In pursuant to the bills issued by the op/nursing home the complainant paid necessary charges to the op/nursing home authority towards LUCS operation of the patient and as such there is no hesitation to hold that the being a beneficiary the complainant is to be treated as consumer within the meaning and purview of Consumer Protection Act, 1986. 30. Now whether there is any wrong, error or mistake committed in blood transfusion to the patient at the premises of the opposite party/nursing home that should be decided and adjudicated by this Commission in order to meet proper and actual justice to the parties. 31. In pursuant to the above observations it is clear to us that on 26/12/2014 at about 1 AM due to profuse bleeding the patient was underwent serious condition and as per instruction of the hospital and their requisition, the complainant collected two units of blood (A+) and submitted the same to the hospital authority accordingly. 32. Upon careful perusal of the REPORT OF CROSS-MATCH/COMPONENT ISSUE FORM, there is no such doubt that the patient needed the group of A+ blood. 33. Now we have carefully perused the bed head ticket issued by op/nursing home wherefrom it appears to us that one unit of blood being no. IBT-14-1304-22/WB was transfused to the patient on 26/12/2014 at 7 AM and thereafter another unit being no. IBT-14-1304-62/WB was also transfused to the patient on the self same date ie on 26/12/2014 at 12 PM. 34. But surprisingly we find an endorsement as H/O MISMATCHED BLOOD TRANSFUSION clearly appended at the left side on the back side of the bed head ticket and the aforesaid endorsement has been made on the self same date ie on 26/12/2014 at 8PM. 35. Regarding this event the complainant wrote two letters dated 09/02/2015 and 12/03/2015 addressed to the op/nursing home wherefrom it appears to us that the complainant prayed for supplying the relevant documents regarding wrong blood transfusion. But no documents were supplied to the complainant. In this connection the complainant moved before the Consumer Affairs Department, Govt of West Bengal for mediation and to that effect a complaint was lodged against the op/nursing home. Notice was served upon the opposite party. On 25/05/2016 both parties were present and the opposite party requested for 7 days for submitting relevant documents. But on the next date 16/06/2016 the opposite party failed to provide the relevant documents and papers to the complainant which is clearly revealed from the note sheet of the mediation conducted by the Consumer Affairs Dept, Govt of West Bengal. Be that as it may we find simply non co-operation from the end of the op/nursing home regarding supplying of the documents. At this juncture it is evident that though the op/nursing home provided some documents to the complainant but did not provide rest documents and papers to the complainant till 16/06/2016 as promised earlier and for that reasons the complainant filed the instant consumer case before this Commission on 21/12/2016 without back side of the bed head ticket along with other documents. 36. By filing evidence on affidavit the opposite party/nursing home stated that as per C.E Act 2007, the authority concerned already disposed the original BHT or medical paper after two years from the cause of action. So at this stage the op is unable to file the same before this Commission. At the same time the op stated that all medical papers along with BHT were already handed over to the complainant at the time of discharge of the patient. In pursuant to the above observations we find simply contradictory statement on the part of opposite party. At this juncture there is no hesitation to hold that the opposite party plays a trick in order to fill up their lacuna. 37. In the petition of complaint the complainant averred that at 4 PM (visiting hour) on 26/12/2014 the patient cried out and drew the attention of the complainant showing that the blood packet was wrong one ie B+ which was for another patient viz. Ranu Das. But already the blood transfusion was started at about 12 noon. Actually it was fact that the B+ blood was already transfused to patient instead of A+ blood and the same is clearly corroborating to the endorsement as H/O MISMATCHED BLOOD TRANSFUSION dated 26/12/2014 appended left side on the back side of bed head ticket issued by OP/Nursing Home authority. 38. The ld advocate appearing for the op/nursing home submitted a medical journal (source-Wikipedia) regarding postanesthetic shivering (PAS). It means kind of shivering after anesthesia. PAS is one of the leading causes of discomfort in patients recovering from general anesthesia. The ld advocate appearing for the opposite party argued that the patient was shivering and felling discomfort due to cause of general anesthesia during the post operative period of operation. 39. Against this argument complainant agitated that due to transfusion of wrong blood ie B+ (instead of A+) on 26/12/2014 at about of 4 PM the complainant was felling huge cold and for that reasons the patient was covered with 4 numbers of blankets. The complainant requested the hospital authority on several occasions but the concerned authority did not pay any heed. 40. In pursuant to the aforesaid arguments between the parties it should be required to peruse the medical journal /journals regarding effects of wrong blood transfusion to the patient otherwise we cannot reach the conclusion in order to meet proper justice to the parties. 41. According to the medical journal, the many medical experts say that it will be very bad if the recipient’s body is transfused with wrong blood type, at this time, an acute haemolytic transfusion reaction can occur in the recipient about 24 hours after receiving the blood or may occur during blood transfusion error. The patient is the one who will feel these changes most clearly, the body may have symptoms such as heat at the blood transfusion site, fever, chills, pain in the back sides, breathing difficulties, muscle aches, chest pain, blood in urine, jaundice etc. The accidents caused by blood transfusions of different groups (whether full or partial transfusion) can cause fast or slow reactions, even endanger the patient’s life. Therefore, before conducting blood transfusion, it is necessary to ensure the principles and strictly follow the indications for blood transfusion when necessary and if it is not followed strictly by the staff of the concerned hospital or doctor, definitely medical negligence on their part would be occurred. 42. As per above observations we find one of the reaction/effect which is feeling chills in the body of the patient. In pursuant to the Webster dictionary CHILL means a feeling of cold accompanied by shivering. It also means a moderate but unpleasant amount of cold. In the instant case at about 4 PM on 26/12/2014 the patient was felling huge cold and the hospital authority provided 4 blankets to the patient in order to keep the body hot. At this juncture, the Ld. Advocate has taken the plea that after anaesthesia shivering may be occurred. But upon careful perusal of the record , we find that anaesthesia has been done at the time of operation of the patient on 25.12.2014 at night. But the fact remains that shivering has been occurred at 12.00 Noon on the next date i.e. on 26.12.2014, when the wrong blood has been transfused to the patient. So, there is no chance to believe that due to postanesthetic shivering (PAS), the patient was feeling cold/chill. Rather, it is evident that the patient was suffering discomfort as an adverse effect (just like as cold/chill) due to wrong blood transfusion and to that effect four numbers of blankets were provided to the patient in order to keep the body of the patient hot. So, the plea taken by the OP for not providing four blankets is totally false and misleading. 43. At the time of final hearing the ld advocate appearing for the opposite party/nursing home urged that the complainant caused damage the property of the nursing home. But we think that the OP tried to fill up their lacuna by taking that type of plea as no FIR was lodged against the complainant, no General Diary/complaint was filed against him. The mere argument on this particular point has no leg to stand upon. 44. Upon whole observations in details we there hold that wrong blood transfusion was made by the staff/staffs of the op/nursing home. Due to wrong blood transfusion the patient was suffering from huge cold (chill) as an adverse effect and to control the situation 4 blankets were given to the patient in order to keep the body of the patient hot and or removing from shivering. Regarding supply of documents we can safely hold that the op/nursing home did not provide full set of the documents along with BHT as per requests of the complainant within the reasonable period of time and in this regard the op/nursing home delivered contradictory statement in their evidence. Be that as it may in written version the OP clearly stated that some documents were delivered to the Complainant. So, it is evident that the OP failed to deliver the full set of document to the Complainant. There is a clear error or mistake in transfusion of blood to the patient and mistake on the part of the op is hereby proved. We find clear gross negligence or fault on the part of the op/nursing home and the complainant is entitled to get relief against the opposite party. 45. Under such circumstances we can safely rely upon the citation POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION AND RESEARCH CHANDIGARH VS JASPAL SINGH AND OTHERS, wherein the Hon’ble Supreme Court has been pleased to hold that transfusion of wrong blood is surely a medical negligence. When the wrong blood transfusion takes place in a hospital endangering the life of a patient, the doctor cannot escape being charged under medical negligence as by no stretch of imagination could it be termed as an error in professional judgment. The wrong blood transfusion is an error which no hospital/doctor exercising ordinary care would have made. Such an error is not an error of professional judgment but it is the very nature of things a sure instance of medical negligence. 46. Reliance upon another citation M/S-SAMAD HOSPITAL AND OTHERS VS S. MUHAMMED BASHEER AND OTHERS in First Appeal no . 172/2012 wherein the Hon’ble NCDRC has been pleased to hold that in most of the cases the hospital staff failing to respond the signs and symptoms of blood transfusion error. Thus the cause can be as simple as breakdown in safety protocols or poor training. 47. So, at the threshold , it is brought to our notice that Bolam Protocol/test has not been maintained and followed by the OP/Nursing Home authority in proper way. 48. Considering all aspects from all angles and keeping in view of the present position of law and regard being had to the citations of the Hon’ble Apex Court and Hon’ble NCDRC we are constrained to allow the petition of complaint against the opposite party/nursing home on contest with cost and accordingly It is ORDERED That the op/nursing home is directed to pay compensation amounting to Rs.10,00,000/- ( Rupees ten lakh) only to the complainant within 45 days from the date of passing of this order. That the op/nursing home is further directed to pay litigation cost amounting to Rs.20,000/- (Rupees twenty thousand) only to the complainant within the aforesaid period of time in default the whole awarded amount of Rs. 10,20,000/-( Rupees ten lakh twenty thousand) only shall carry interest @ 10% pa from the date of filing of the consumer case till full realization. In case of non-compliance of order by the op/nursing home, the complainant is at liberty to put the order in execution. The instant consumer case stands dispose of as per above observations. Note accordingly. |
| [HON'BLE MR. JUSTICE MANOJIT MANDAL] |
| PRESIDENT |
| [HON'BLE MRS. SAMIKSHA BHATTACHARYA] |
| MEMBER |
| [HON'BLE MR. SHYAMAL KUMAR GHOSH] |
| MEMBER |
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