Medicolegal case

Issue 7

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Case 6: A case of alleged deficiency in service on the part of the opposite pares in a paent with delusional disorder

Judgment:

Ÿ The State Consumer Dispute Redressal Commission stated that it has to be proved that whether the complainant was suffering from mental illness like delusion or any other mental illness or not?

Ÿ The Commission further observed that the District Forum blindly passed an order without considering any expert witness.

Ÿ The State Commission further stated that the District Forum could have sent the complainant to a medical board for expert report in the circumstance.

Ÿ Therefore, the commission decided to interfere in the impugned order passed by the District Forum which was not at all legally sustainable.

“Therefore the appeal was allowed in part and the case was remanded back to the District forum for fresh disposal aer considering and following the provisions of The Mental Health Act 1987, and giving ample opportunies to both sides for adducing expert evidences.”

A case of medical negligence on the treating psychiatrist and hospital alleged because of the suicide committed by a psychiatric patient

The complainants are the parents, brother and sister of the deceased Mr. S who died on 26.11.98 by jumping from the top floor of the 1st opposite party hospital.

Case of the complainant

Ÿ The deceased was a 2nd year Automobile Engineering student studying at a Polytechnic College.

Ÿ OncomplaintoffeverhewastakentoDr.V,AssistantSurgeon,GHospitalon19.11.98.

Ÿ As there was no improvement in the paent ll 20.11.98, he was taken to K Medical Centre, and from there he was referred to a Psychiatrist to the OP1 hospital wherein he was admied on 20.11.98 at 11PM.

Ÿ On the next day he was examined by the psychiatrist (OP2) of the opposite party hospital. Dr. D, a Neurologist also examined the paent.

Ÿ On the same day CT scan of the brain was taken and the treatment was connued for psychiatric disorder and the paent was admied in the hospital.

Ÿ On23.11.98thepaentbecameviolentonaccountofpsychiatricproblems.

Ÿ According to the complainant, he was then shied to ICU as directed by OP 2 and OP3,

the Physician of OP1 hospital.

Ÿ ThebystanderswerenotpermiedintheICU.

Ÿ The days 24th and 25th were unevenul. At about 4.50 am in the morning of 26.11.98 the nursing assistants came to the room where the bystanders were staying and enquired about the paent.

Ÿ By 5.30 am the bystanders were informed that the paent jumped from the top floor of the hospital and that he is in serious condion.

Ÿ Hesuccumbedtotheinjuriesat6.30AM.

Ÿ Complainant contended that the deceased was having psychic problems and was under treatment for the same and that the opposite pares did not take adequate care to see that the paent is kept under close guard.

Ÿ ThecomplainantshaveclaimedasumofRs.19,50,000/-ascompensaon.

Tesmonies of witnesses for the complainant Mr. P and Mr. R referred to as PW1 and PW2, respecvely

PW1

Ÿ PW1isthe1stcomplainant/fatherofthedeceased.

Ÿ He has stated that the deceased was taken to K hospital and that the doctor therein directed the paent to be examined by a Psychiatrist and hence he was taken to the OP1 hospital.

Ÿ He stated that he was not aware as whether any reference leer was given as the paent was taken to the hospital by his another son and his friend.

Ÿ According to PW1, it was on 23rd that his son started refusing to obey instrucons. He was not allowing to administer injecons.

Ÿ It was then that he was shied to ICU. PW1 was not aending paent in the hospital and hence could not answer quesons with reference to treatment as such.

Ÿ Hehasdeniedthathissonhadsustainedaheadinjuryearlier.

PW2

Ÿ PW2istheneighbourandfriendofthedeceasedwhowasthebystanderatthehospital.

Ÿ He has tesfied that the deceased was speaking irrelevantly on account of high fever and that he was taken to the G hospital and aer that to the private hospital.

Ÿ On advice of the doctors at private hospital, he was taken to the OP1 hospital for psychiatrist consultaon.

Ÿ Accordingtohim,thedeceasedbecameviolenton23rdandthereaerhewasadmied at ICU. He has also denied that the deceased had sustained head injury.

Case of the opposite pares

OP1 (hospital)

Ÿ OP1 represented by its Managing Director stated that the paent was admied on 20.11.98 at 11 PM with a history of fever since 3 days.

Ÿ He was under treatment at a local hospital for fever and was reportedly disoriented and talking irrelevantly since morning.

Ÿ The duty doctor was also informed that the paent has a history of black out one month back.

Ÿ Consultaon with the psychiatrist and medical consultaon was also suggested by the duty doctor.

Ÿ The Psychiatrist and Physician had also examined the paent on 21.11.98 in order to find out whether there was any organic brain illness since the paent was having fever along with abnormal behaviour.

Ÿ The paent was having fever of 100F ̊. There was no neck sffness and kernigs signs were negave.

Ÿ Since it was reported that the paent had a history of fall and a consequent hit on the head resulng in a head injury, the Physician (OP3) had advised CT scan of the brain as well as a CSF study.

Ÿ Aer seeing the scan report the same were directed to be done in order to rule out meningoencephalomyelis since the paent had presented with fever and abnormal behaviour.

Ÿ Blood and urine roune examinaons in addion to widal, mantoux, smear for malarial parasite etc. were done.

Ÿ As no specific diagnosis could be arrived, a Neuro Physician Dr. D also examined the paent. There were no neurological deficits observed by the Neuro Physician also.

Ÿ Anbiocs amclox, taxim, tab zevit, tab dolo were prescribed along with the other medicines by the Neuro Physician and Psychiatrist.

Ÿ At about 7.30 pm on 23.11.98 the paent started showing some involuntary movements. Immediately the same was reported to the OP2.

Ÿ Onexaminaonitwasfoundthatthereweresomeinvoluntarymovementsofthelips.

Ÿ Diazepam injecon and injecon epsolin was administered and the Neurologist Dr. D

was informed.

Ÿ The paent was moved to the medical ICU so that he could be observed and monitored connuously in the light of the involuntary lip movements.

Ÿ On 24.11.98 neuro physician advised to avoid sedaves which were likely to create confusion in neuro psychological evaluaon and further suggested to give injecon sernace only if absolutely necessary.

Ÿ Theelectroencephalogramwastakenandwasfoundtobenormal.

Ÿ Other tests like ESR, ANA etc. were done. On 25.11.08 also the doctors examined the paent and found that his vital signs were within normal limits.

Ÿ Neuro Physician advised MRI scan to rule out Accute Disseminated Encephalomyelis (ADEM). The paent was conscious, alert and was talking relevantly at mes and irrelevantly at other mes.

Ÿ Although MRI scan was advised on 25.11.98, the father of the paent informed that the scanning can be done on the next day as he was not able to raise sufficient money for the scan on 25th.

Ÿ At about 4.30 pm on 26.11.98 the paent got out of his bed and aempted to go out of the ICU.

Ÿ The nurses tried to prevent him but the paent pushed aside the duty nurses who had caught hold of him and ran out from the ICU.

Ÿ Though the duty nurses ran aer him but he escaped from the eye sight. Duty nurses and male nurses tried to trace him and alerted the security staff.

Ÿ At last it was found that he had jumped from the top of the hospital and was found lying in the ground.

Ÿ HewasimmediatelyrushedtomedicalICUandwasaendedbythedutydoctors.

Ÿ At about 5 a.m. OP2 and the Anaesthest also came and administered medicines and

connected him to the venlator.

Ÿ However,alltheaemptsofresuscitaonfailedandthepaentdiedat6.30am.

Ÿ It is stated that the first me he showed any violence was at 4.30 am on 26.11.98 when he pushed aside the nurses forcefully and ran out of the ICU.

Ÿ Tillthatmetherewasnothinginhisbehaviortosuspectanyviolentbehavior.

Ÿ No addional security staff is provided in the ICU. It is the duty nurses and male nurses

that manage the condion of the paent in the ICU.

Ÿ The behavior of the paent on the 26th was not predicted or ancipated. He further denied any negligence on the part of the staff of the hospital in taking care of the paent.

OP2

Ÿ OP2, a Psychiatric Consultant at OP1 hospital has tesfied that on examinaon the paents, he felt that the paent was in a delirious state due to organic illness of the brain.

Ÿ He stated that the paent was having history of black out one month back. He further stated that no psychiatric treatment was provided to the paent.

Ÿ Hehadadministeredmedicinestocontrolbehaviorproblemsinthedeliriousstate.

Ÿ He has also stated that haloperidol injecon and phenergan injecon were

administered.

Ÿ Sernace was also administered. Sertalin was administered as the paent had slight anxiety.

Ÿ AsdirectedbytheNeuroPhysician,injeconSernaceandEpsolinwerestopped.

Ÿ He further admied that Sertalin as per the recommendaons of the Food and Drug Administraon, if administered to persons aged 18 to 25 as andepressant, there will be suicidal tendency and that they should be closely monitored.

Ÿ However, same is not the case in the maer of the deceased. Only a minimum dose of Sertalin was administered to the deceased and that on account of the same there is no chance of having the suicidal tendency.

Ÿ He also stated that diazepam was also given to the deceased in a minimum dose. If the paent is in a delirious state he may show violence.

Ÿ He further stated there will be no side effect if the above medicines are administered in the proper dose which was in done in the present case.

OP3

Ÿ OP3istheChiefPhysicianoftheOP1hospital.

Ÿ He contended that the deceased was administered with medicines prescribed by the

Neuro Physician and Psychiatrist.

Ÿ At about 9.30 pm on 23.11.98, the paent was showing some involuntary movements of the lips.

Ÿ Hence,thetreatmentwasprovidedinconsultaonwiththeNeuroPhysician.

Ÿ He has stated that with one dose of diazepam there will be no tendency to commit suicide. Such tendency is possible due to long usage.

Ÿ He further stated that more possibility of organic brain disease was considered as the paent had fever and fits.

Ÿ If there is fever there will be infecon. In such cases abnormal behaviour is shown and if the paent is violent in such cases the Psychiatrist is consulted.

Ÿ Only with an MRI scan a proper diagnosis as to whether the infecon has affected the brain can be made.

Ÿ He has also stated that in the present case there was fever and fits and hence, a possibility of developing severe fits. Therefore, the paent was admied in the ICU.

Findings and discussion

Ÿ Itisevidentfromthecasesheetthatthehistoryofblackoutonemonthbackisnoted.

Ÿ Moreover, in the consultaon record on 25.11.98, it is menoned that the paents,

when seated tended to fall to the bed.

Ÿ Itisalsonotedthatwhenhewasmadetostandandaskedtowalkhecouldwalkwithout support.

Ÿ It is further menoned that he used to talk to the nursing staff at mes and wanted to go to the room.

Ÿ The possibility of primary psychiatric problem was considered as the 1st possibility and MRI scan was suggested to rule out the rare possibility of ADEM.

Ÿ It is also menoned in the case sheet that at mes the deceased answered to quesons properly and at mes he refused to talk.

Ÿ The above period was just hours prior to the date of the incident of fall from the top of the hospital.

Ÿ It has been noted in the case record dated 24.11.98 that “on yesterday night the deceased had shown abnormal behaviour with shoung and violent nature.”

Ÿ It further stated that injecon diazepam was given at that me and he was found sedated since then.

Ÿ Evidently since 23.11.98 there was no administraon of diazepam. Admiedly the paent was treated by the specialist doctors in Psychiatry, Medicine and Neurology.

Ÿ It was persisng fevers that lead to the suspicion of the possibility of organic brain illness. Although it was on account of the head injury and black out noted in the history.

Ÿ Itisthecaseoftheoppositeparesthatsomesortofabnormalbehaviourwillbeshown by the paent afflicted with ADEM.

Ÿ It has been also noted that although in the version filed by the opposite pares, the case of head injury and black out was specifically menoned and the same was not denied in the examinaon of PW2.

Ÿ It is only when specifically quesoned in the cross examinaon that they have denied that the complainant had a head injury.

Ÿ InthecircumstancesitappearsthatPWs1and2arenotspeakingthetruth.

Ÿ Moreover, it was evident that only for providing emergency care and constant monitoring of the involuntary lip movements and fever that the paent was shied to the ICU.

Ÿ All possible tests i.e. CT scan, CFS study, EEG and blood test were done. MRI scan although advised could not be done as the father of the deceased could not raise money for the same.

Ÿ It has also to be noted that the Neurologist, Physician and the Psychiatrist in consultaon treated the paent.

Ÿ What was the illness as such could not be diagnosed finally. No medical literature has been produced to substanate that the medicines administered in such doses would result in suicidal tendency.

Ÿ It is also evident that the specialist doctors would not have directed shiing the paent to the ICU, if the paent was violent as in the ICU it is crically ill paents who are admied.

Ÿ Further just an error in judgment or such a mistake in diagnosis cannot be considered as aconable negligence on the part of the opposite pares.

Points for determinaon

Ÿ Were the psychiatrist and the hospital staff negligent in not managing the condion of the paent in the ICU?

Ÿ Didtheprescribedmedicinesortheirdoseledtosuicidaltendencyinthispaent?

Ÿ Canapsychiatristbeheldguiltyfornotancipangtheaconsofapsychiatricpaent?

Ÿ Do the hospital record anywhere hint to a medical negligence or do they clearly support the services of the treang doctors?

Ÿ Can the hospital staff, parcularly the ones in the ICU be alleged of carelessness in managing the paent resulng in his death?

For the use of registered medical praconer or a hospital or a laboratory only.

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