New Delhi: Taking note of the error on the part of the Thiruvananthapuram-based Samad Hospital and its doctor while managing a patient who underwent laparoscopic surgery at the hospital, the National Consumer Disputes Redressal Commission (NCDRC) recently held them guilty for wrong blood transfusion to the patient that ultimately led to her death, around 20 years ago.

Therefore the top consumer court has directed the Hospital and Dr. Sathi M. Pillai to pay a lump sum compensation of Rs 20 lakh to the family of the deceased.

While considering the matter, the NCDRC bench also referred to the fact that in most of the cases the hospital staff fail to respond to the signs and symptoms of blood transfusion error.

“Though most hospitals and surgical centres have strict procedures on blood storage, but sometimes improper or poorly stored blood got issued. Reporting all transfusion-related adverse reactions to the Blood Bank promptly is more vital,” further noted the bench as it opined that transfusion reactions and adverse events should be investigated by the clinical team and hospital transfusion team and reviewed by the hospital transfusion committee.

Such observations came from the consumer court while considering a complaint by a married couple who were undergoing treatment for infertility at Samad Hospital, Thiruvananthapuram back in 2002. The abdominal Ultrasonography (USG) scan revealed fibroid uterus and advised laparoscopic removal of the fibroids. Therefore the patient underwent laparoscopic surgery and following that, she had been shifted to the post-operative ward.

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In the evening the doctor who was treating the patient, Dr. Sathi M. Pillai, asked for blood transfusion, which started at 8.30 p.m. However, the patient started developing blood transfusion reactions and complications. Therefore, the patient was referred to Kerala Institute of Medical Sciences (KIMS) in a critical state. She had developed DIC with haemoperitonium, acute respiratory distress and acute renal failure.

Meanwhile, one of the staff of the Samad Hospital allegedly disclosed to the family members of the patient that the Hospital had committed a mistake by giving B group blood instead of O group blood. It was allegedly confirmed by the Consultant Physician at KIMS Hospital Thiruvananthapuram. Therefore, being aggrieved by the alleged negligence during the blood transfusion and further treatment, the Husband of the patient and other relatives approached the State Commission and prayed for a compensation of Rs 45 lakh along with the interest. 

During the pendency of the case, the husband of the patient died in a road accident during the pendency
of the complaint before the State Commission. Accordingly, his name was deleted and the parents of deceased along with two
sisters and brother of the patient were added as Complainants.

On the other hand, the doctor and the hospital denied the mismatched blood transfusion and submitted that the patient had developed complications which were beyond their control and expectation. They also claimed that the complications had been promptly treated but the patient had developed DIC (Disseminated Intra Vasculat Coagulation). Therefore, after taking expert consultation from a doctor of Taluk Hospital, the patient had been referred to a higher centre immediately for better management.

After considering the submissions by both the parties, the State Commission had partly allowed the Complaint and directed the hospital and doctor to pay a total compensation of Rs. 9,33,000 to the complainants along with cost of Rs 15,000.

Such a decision was taken by the State Commission as it took note of the fact that half an hour after initiating the blood transfusion at 8.30 p.m., the patient had developed shivering and wetting of surgical wound. The Commission opined that the hospital and doctor failed to follow
the standard procedures after the transfusion reaction. The hospital failed to communicate the
blood bank and not investigated the transfusion reaction by sending the remaining blood bag, patient’s blood and urine samples. Even though the Cross Examination revealed that the reaction started at 9 p.m. no immediate steps were taken by the Samad
Hospital, noted the State Commission.
Further the State Consumer Court had noted that the KIMS Hospital doctor had confirmed that the patient had been brought to the hospital in a critical state and she had developed DIC.
However, challenging the State Consumer Court’s order, the Hospital and the doctor approached the NCDRC bench and the counsel for both the sides reiterated their evidence
adduced before the State Commission. Apart from referring to the State Commission’s order, the bench also took reference from the standard text books on Transfusion
Medicine, Hematology and Internal medicine.
The top consumer court referred to the Case Sheet where the Clinical note had mentioned that the probable cause for
the transfusion reaction as mismatched blood transfusion and the resultant DIG + ARF + severe
bleeding. It is also noted that the patient continues to be oliguric.
Referring to this, the Commission noted,

Thus, in our view, the afore entry itself is sufficient to prove that mismatched blood was transfused to the patient. It was due to the blood bag which was kept in hospital refrigerator and transfused on the fateful day. Moreover, it was the duty of hospital to prove the wrong blood was issued from the Blood Bank , but the Apellant failed to prove it. Proper medical record has more importance. The finding of State Commission show the glaring lapses of the Opposite Parties Nos. 1 and 2, who have not kept the transfusion register showing the number of bags, its date of receipt or use or disposal. Thus, possibility of error in identification of the blood bags or identifying the patients was more.”We, further, note that the blood bag was kept in storage of the Hospital premise. It should be borne in mind that the cross-matched blood received from the blood bank shall be transfused within reasonable time preferably within 24 hours. However, in the instant case, there is no record that when the blood was brought from the blood bank. Therefore, we conclude for Q. (i) that wrong blood was transfused to the patient and the hospital staff is liable for the negligence,” observed the Commission.

While deciding if the patient’s condition was a Mismatched reaction or DIC, the bench referred to the clinical notes of Dr. Valentina and the Anaesthesia notes of KIMS Hospital and decided that it was transfusion reaction.
Referring to the medical literature, the bench noted,

When red blood cells are destroyed, the process is called hemolysis and the hemolytic transfusion reaction is a serious complication that can occur after a blood transfusion, sometimes due to errors. Because humans are involved in every step of the process from collecting blood to storing the blood and administering the blood into an IV, mistakes can occur that can lead to blood transfusion errors. The errors include mislabeled blood, wrong patient receiving a blood transfusion, the patient receiving the wrong blood type. The most serious reactions are caused by transfusion of ABO-incompatible red cells which react with the patient’s anti-A or anti-B antibodies. There is rapid destruction of the transfused red cells in the circulation (intravascular haemolysis) and the release of inflammatory cytokines. The patient often quickly becomes shocked and may develop acute renal failure and disseminated intravascular coagulation (DIC). Transfusion of less than 30 mL of group A red cells to a group O patient has proven fatal 14.”“In most of the cases the hospital staff failing to respond to the signs and symptoms of a blood
transfusion error. Thus the cause can be as simple as a breakdown in safety protocols or poor
training. Though most hospitals and surgical centres have strict procedures on blood storage, but
sometimes improper or poorly stored blood got issued. Reporting all transfusion-related adverse
reactions to the Blood Bank promptly is more vital. Haemovigilance is the ‘systematic
surveillance of adverse reactions and adverse events related to transfusion’ with the aim of
improving transfusion safety. Transfusion reactions and adverse events should be investigated by
the clinical team and hospital transfusion team and reviewed by the hospital transfusion
committee,” the Commission observed as it referred to the instances of negligence in Blood Transfusion error.

At this outset, the Commission referred to the Supreme Court order in the case of Postgraduate Institute of Medial Education
and Research Chandigarh vs. Jaspal Singh & Others wherein it had been held that mismatch in transfusion of
blood resulting in death of the patient after 40 days, a case of medical negligence.
Referring to this, the Commission noted,

“In the instant
case wrong blood transfusion to *** (patient) was an error which no hospital/doctor exercising
ordinary care would have made. Such an error is not an error of professional judgment but in the
very nature of things a sure instance of medical negligence and the hospital’s breach of duty
contributed to her death. Thus, we have no hesitation to hold the Opposite Party No. 1 and 2 liable
for deficiency in service and the medical negligence.”

Although the NCDRC bench agreed on the State Commission’s order, it modified the compensation amount and allowed a lump sum compensation of Rs. 20 lakh to the parents of the deceased.
“Based on the foregoing discussion, the Appeal is dismissed with modification to the Order
of the State Commission. The Appellants shall jointly and severally pay Rs. 20 lakh as a
compensation and Rs. 1 lakh towards the cost of litigation within 6 weeks from today to the
parents of deceased Sajeena. Any delay beyond 6 weeks, shall attract interest @ 7% per annum
till its realization,” read the order.
To read the order, click on the link below.

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