Lack of Pre-operative Management before Retrograde Pyelogram, Ureteroscopy: Max Hospital, Surgeon told to pay Rs 2 lakh compensation

Chandigarh: The State Consumer Disputes Redressal Commission, Punjab has recently held Mohali-based Max Super Specialty Hospital and its surgeon guilty of medical negligence while performing Retrograde Pyelogram (RGP) and Ureteroscopy (URS) surgery upon a patient, whose ureter got damaged in the process.

Such a decision was taken by the State Consumer Court as it took note of the fact that the hospital and the surgeon Dr. Rai, withheld pre-operative investigations and conservative management record, which was required before the operation. Further, the pre-operative consent had also not been taken by them.

Taking note of the fact that the patient was suffering from fever during admission, the Commission observed, “Due to inflamed issues, there were chances of manipulation intervention and that enhances the risk of complication. It was incumbent upon the OPs that if there was infection and inflammation, to have treated the patient conservatively to control the infection and inflammation first, before proceeding to operate upon the patient.”

The history of the case goes back to 2019 when the complainant suffered pain in the right side of the abdomen and approached Shri Dhanwantry Ayurvedic
College and Hospital, where USG was conducted. A
stone was found in his ureter on right upper side and impressions of
Bilateral renal concretions and Grade II fatty infiltration of liver were also
mentioned in the said USG report.

Also Read: Urinary Bladder cut during emergency operation for labour: Nursing Home directed to pay Rs 4 lakh compensation

Thereafter, he got admitted to Max Super Specialty Hospital, Mohali. After conducting various tests, the patient had been diagnosed with Upper Ureteric Calculus.

It was alleged by the complainant that the hospital and the doctor did not conduct any test to locate the position
of the stone in the ureter. Following this, the surgeon of the hospital, Dr Rai performed Retrograde Pyelogram
(RGP) and Ureteroscopy (URS) surgery. The physician injected a radiocontrast agent into the ureter
in order to visualize the ureter and kidney with fluoroscopy or
radiography in a urologic procedure i.e. Retrograde Pyelogram.
It had also been alleged by the complainant that the hospital and doctor recorded that the
ureteroscope could not be negotiated beyond mid-ureter, so on
withdrawing back the scope from ureter, which suddenly gave way and
suspected to be avulsed.
He further alleged in his complaint that the ureter was injured from two sides while
withdrawing the scope from the ureter. Further it had been alleged that the hospital and doctor abandoned the
procedure due to said reasons and performed nephrostomy and wound
was closed leaving the tube drain.
Although the complainant had been informed that for
repair of the damaged ureter, an attempt was required to be made, he alleged that no corrective surgery was performed and the
complainant was discharged on 28.05.2019 with urine collection bag.
He was asked to come for a follow up after seven days and the discharge summary mentioned that “a plan would be for ileal ureter replacement
after 3 months”, which was a reconstruction of urinary tract.
Besides, the complainant also alleged that before conducting the said surgery, no X-ray of abdomen and USG
was conducted by the hospital and doctor, which has resulted into injury.
Following this, the complainant approached the Postgraduate Institute of
Medical Education and Research, Chandigarh (PGIMER), where his injured ureter was recreated after taking
a piece from small intestine of the complainant.
Claiming that he had to suffer physically and mentally, the complainant claimed a compensation of Rs 20 lakh along with Rs 1 lakh for litigation expenses.
To support his allegations, the complainant filed his affidavit, and he also submitted several evidence including the copy of the ultrasound report, discharge summary of Max Hospital, bills, medical record at PGIMER etc.
The counsel for the complainant submitted that there was rupture at two places while conducting the surgery. He also claimed that in order to get rid of the complainant and save their skin, the hospital and the surgeon allegedly left the patient in pain and discharged him with catheter.
On the other hand, the hospital and the surgeon submitted that the complainant had been admitted with high fever and his USG report reflected the position of stones. Therefore, they argued that no further investigation was required. They also claimed that the hospital and the doctor performed retrograde pyelogram to confirm stones and the patient was
operated with utmost safety and all precaution by adopting URSL or
Uretoscopic lithotripsy, which is most effective by adopting minimal
procedure for the patient.
It was their argument that the unfortunate situation arose, not due to lack of any skill or competence of the
Doctor/s or proper care but because of inflammation, which had
occurred due to chill fever and pain for days. The report also reflected
that stones were tightly encapsulated due to inflammation and
granulation issue and as such, while retracing the said avulsion had
occurred, for which complainant was advised for follow up, they contended.
Further, they pointed out that even in PGI Laparoscopic Surgery was planned but
it was converted into open surgery. Therefore, the procedure adopted
by the concerned doctor was not contrary to any medical journal.
After taking note of the submissions by both the parties and also going through the medical record, the Consumer Court noted, “The sequence of events clearly proves that the complainant
had approached OP No.1; by relying upon the report of USG Exhibit C1, OPs proceeded to operate the complainant. On the basis of Exhibit C-2, the complainant was advised CBC (Complete Blood Count)
besides other tests. However, the OPs handed over all the reports to
the complainant except CBC (Complete Blood Count). If the OPs had
produced the CBC report, it would have exposed them that there was
infection coupled with inflammation due to which, there were
possibilities of complication.”
“Due to inflamed issues, there were
chances of manipulation intervention and that enhances the risk of
complication. It was incumbent upon the OPs that if there was infection
and inflammation, to have treated the patient conservatively to control
the infection and inflammation first, before proceeding to operate upon
the patient. This appears to be the only reason why OPs have withheld
the CBC report. Though avulsion is a rare complication; however, this
could have been avoided. The fact that the patient had infection and
consequent inflammation finds support from the discharge summary
Exhibit C-3, prepared by OPs,” further noted the court.
Opining that the complication in the surgery could have been avoided, the bench noted,

“Despite this, the OPs instead of adopting conservative
treatment to control the infection, rushed to operate the patient to avoid
losing patient. The OPs admitting inflammation to be the cause of
narrowing the passage of ureter which further led to avulsion while
retracting. This complication could have been avoided, had the OPs
instead of rushing to operate initially adopted, conservative treatment.”

Therefore, holding the hospital and the surgeon guilty of medical negligence, the order mentioned,

“The OPs withheld the pre-operative investigations and
conservative management record, which was required before operation.
OPs had also withheld this pre-operative consent of the complainant or
his family members and only brother was informed about the
complication, as wife was not available. It is mandatory requirement of
medical procedure that unless the situation is so emergent that there is
threat to the life of the patient and it is not possible to wait for the
consent that the doctor can operate without waiting for the consent.
Otherwise, pre-operative consent is mandatory which has not been
obtained by the OPs for reasons best known to them, as to why the OPs had to proceed with the surgery without pre-operative consent as
well as high risk consent. From this, the negligence of the respondent
stands fully established.”

The State Commission also referred to the Supreme Court’s judgment in the case of V. Kishan Rao v. Nikhil
Super Specialty Hospital, where it had been held by the top court that in a case
where negligence is evident, the principle of res ipsa loquitur operates
and the complainant does not have to prove anything as the thing (res)
proves itself.
Referring to this judgment, and also considering the pain and suffering of the complainant, the consumer court allowed the complaint and awarded Rs 2 lakh as compensation to the complainant along with Rs 15,000 for litigation expenses.
To read the case order, click on the link below.

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