case of suicide committed by a patient with psychiatric disorder while undergoing treatment in the hospital

WATCH SERIES

Medico Legal Case in

PSYCHIATRY

A case of suicide committed by a patient with

psychiatric disorder while undergoing treatment in

the hospital

(Source: h ps://indiankanoon.org/doc/119573600/)

Summary

The deceased was an engineering student. On complaint of fever and irrelevant talking, he was taken to Dr. V at a government hospital. However, there was no improvement in the condi on of the pa ent and hence, he was taken to K Medical Centre from where he was referred to the psychiatrist at the OP1 hospital on 20.11.98 and was examined by OP2, a psychiatrist. On 23.11.98, the pa ent became violent due to psychiatric problems and was shi ed to the ICU. On 26.11.98, the nursing assistants informed the deceased rela ves who were in other room that the pa ent had jumped from the top floor of the hospital and that he is in serious condi on. The pa ent ul mately succumbed to his injuries at 6:30 a.m. Therefore, the complainants have claimed a sum of Rs.19,50,000/- as compensa on.

The opposite par es (OPs) filed their versions of the case. OP2 averred that the pa ent was admi ed on 20.11.98 with the history of fever since 3 days and was reportedly disoriented and talking irrelevantly since morning. On 23.10.98, the pa ent became restless and showed some involuntary lips movements. OP2 then consulted OP3 a neuro physician who advised to administer injec on diazepam and epsolin and shi the pa ent to medical ICU. Since the pa ent had persistent temperature, abnormal pa ern of behavior, fits and also had a history of blackout and head injury, a possibility of organic brain disease was considered. Therefore, in order to con nuously monitor the involuntary lip movements and for providing emergency the pa ent was shi ed to the ICU. Various tests were done to rule out the possibility of any medical pathology and neurological problems. On

25.11.98, neuro physician advised MRI scan. However, the father of the pa ent 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. At 4:30 a.m. on 26.11.98, the pa ent got up from his bed and a empted to go out of the ICU, when nurses tried to stop him; he pushed the nurses aside and ran away. Nurses tried to trace him and alerted the security. At last it was found that he had jumped from the top of the hospital. OPs were called who tried to save his life but he ul mately succumbed to his injuries.

The court a er hearing both the par es referred to the case sheet of the pa ent where it was recorded that he had shown abnormal behavior with shou ng and violent nature and injec on diazepam was given at that me and he was found sedated since then. Evidently it is only for providing emergency care and constant monitoring in view of the involuntary lip movements and fever that the pa ent was shi ed to the ICU. All possible tests i.e. CT scan, CFS study, EEG and blood test were done. No medical literature was produced to substan ate that the medicines administered in such doses would result in suicidal tendency. It has also to be noted that the Neurologist, Physician and the Psychiatrist in consulta on treated the pa ent. Further just an error in judgment or such a mistake in diagnosis cannot be considered as ac onable negligence on the part of the opposite par es. In the result the complaint was dismissed.

The complainants are the parents, brother and sister of the deceased Mr. S who died on 26.11.98 in consequence to a empt to commit suicide 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 the Polytechnic, Kalamassery.

Ÿ On complaint of fever he was taken to Dr. V, Assistant Surgeon, G Hospital, Vadavukode on 19.11.98.

Ÿ As there was no improvement, on 20.11.98 he was taken to K Medical Centre, Thripunithura and from there he was referred to a Psychiatrist to the OP1 hospital wherein he was admi ed on 20.11.98 at 11 p.m.

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

Ÿ On the same day CT scan of the brain was taken and the treatment was con nued for psychiatric disorder.

Ÿ He was admi ed in room No.307. On 23.11.98 the pa ent became violent on account of psychiatric problems.

Ÿ According to the complainant, the pa ent was then shi ed to ICU as directed by OP 2 and OP3, the Psychiatrist and Physician of OP1 hospital.

Ÿ The bystanders were not permi ed in the ICU.

Ÿ The days 24th and 25th were uneven ul. At about 4.50 a.m. in the morning of 26.11.98 the nursing assistants came to room No.307 where the bystanders were staying and enquired about the pa ent.

Ÿ By 5.30 a.m. the bystanders were informed that the pa ent jumped from the top floor of the hospital and that he is in serious condi on.

Ÿ He succumbed to the injuries at 6.30 a.m.

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

Ÿ The complainants have claimed a sum of Rs.19,50,000/- as compensa on.

Tes monies of witnesses for the complainant Mr. P and Mr. R referred to as PW1 and PW2, respec vely

PW1

Ÿ PW1 is the 1stcomplainant/father of the deceased.

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

Ÿ He is not aware as whether any reference le er was given as the pa ent was taken to the hospital by his another son and a friend.

Ÿ It was on 23rd that his son started refusing to obey instruc ons. He was not allowing to administer injec ons.

Ÿ It was then that he was shi ed to ICU. He was not a ending the pa ent in the hospital and hence could not answer ques ons with reference to treatment as such.

Ÿ He has denied that his son had sustained a head injury earlier.
PW2

Ÿ PW2 is the neighbor and friend of the deceased who was the bystander at the hospital.

Ÿ He has tes fied that the deceased was speaking irrelevantly on account of high fever and that he was taken to the G hospital and a er that to the private hospital at Thripunithura.

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

Ÿ According to him the deceased became violent on 23rd and there a er he was admi ed at ICU. He has also denied that the deceased had sustained head injury.

Case of the opponent

OP1 (hospital)

Ÿ OP1 represented by its Managing Director stated that the pa ent was admi ed on 20.11.98 at 11 p.m. 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 pa ent had a history of black out one month back.

Ÿ Consulta on with the psychiatrist and medical consulta on was also suggested by the duty doctor.

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

Ÿ The pa ent was having fever of 100°F. There was no neck s ffness and kernigs signs were nega ve.

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

Ÿ A er seeing the scan report the same were directed to be done in order to rule out meningoencephalonli s since the pa ent had presented with fever and abnormal behaviour.

Ÿ Blood and urine rou ne examina ons in addi on 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 pa ent. There were no neurological deficits observed by the Neuro Physician.

Ÿ An bio cs (Amclox), taxim, tab zevit, tab dolo were prescribed along with the other medicines by the Neuro Physician and Psychiatrist.

Ÿ At about 7.30 p.m. on 23.11.98 the pa ent started showing some involuntary movements. Immediately the same was reported to the OP2.

Ÿ On examina on it was found that there were some involuntary movements of the lips.

Ÿ Diazepam injec on and injec on epsolin was administered and the Neurologist Dr. D was informed.

Ÿ The pa ent was moved to the medical ICU so that he could be observed and monitored con nuously in the light of the involuntary lip movements.

Ÿ On 24.11.98 Neuro Physician advised to avoid seda ves which were likely to create confusion in Neuro psychological evalua on and further suggested to give injec on Sernace only if absolutely necessary.

Ÿ The electroencephalogram was taken and was found to be normal.

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

Ÿ Neuro Physician advised MRI scan to rule out Acute Disseminated Encephalomyeli s (ADEM). The pa ent 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 pa ent 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 4.30pm on 26.11.98 the pa ent got out of his bed and a empted to go out of the ICU.

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

Ÿ Though the duty nurses ran a er 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 lying on the ground.

Ÿ He was immediately rushed to medical ICU and was a ended by the duty doctors.

Ÿ At about 5 a.m. OP2 and the Anesthe st also came and administered medicines
and connected him to the ven lator.

Ÿ However, all the a empts of resuscita on failed and the pa ent died at 6.30 a.m.

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

Ÿ Till that me there was nothing in his behavior to suspect any violent behavior.

Ÿ No addi onal security staff is provided in the ICU. It is the duty nurses and male
nurses that mange the condi on of the pa ent.

Ÿ The behavior of the pa ent on the 26th was not predicted or an cipated. OP1 had denied any negligence on the part of the staff of the hospital in taking care of the pa ent.
OP2

Ÿ OP2, a Psychiatric Consultant for OP1 hospital has tes fied that on examina on he felt that the pa ent was in a delirious state due to organic illness of the brain.

Ÿ He stated that the pa ent was having history of black out one month back. He

further stated that no psychiatric treatment was provided to the pa ent.

Ÿ He had administered medicines to control behavior problems in the delirious state.

Ÿ He has also stated that haloperidol injec on and phenergan injec on were administered.

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

Ÿ As directed by the Neuro Physician injec on Sernace and Epsolin were stopped.

Ÿ He further admi ed that Sertalin as per the recommenda ons of the Food and Drug Administra on if administered to persons aged 18 to 25 as an depressant produces suicidal tendency and that they should be closely monitored.

Ÿ However, same is not the case in the ma er 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 pa ent 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 OP3 is the Chief Physician of the OP1 hospital.

Ÿ He stated that the pa ent had a history of black out about one month back and
also a history of a fall and consequent hit on the head resul ng in the head injury.

Ÿ Therefore, he had advised CT scan of the brain along with CSF study. All tests were done to rule out meningoencephali s since the pa ent had presented with fever and abnormal behaviour.

Ÿ He further contended that the deceased was administered medicines prescribed by the Neuro Physician and Psychiatrist.

Ÿ At about 9.30 p.m. on 23.11.98, the pa ent was showing some involuntary movements of the lips.

Ÿ Hence, the treatment was provided in consulta on with the Neuro Physician.

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

Ÿ More of a possibility of organic brain disease was considered as the pa ent had fever and fits.

Ÿ OP2 further averred that if there is fever there will be infec on. In such cases abnormal behavior is shown and if the pa ent is violent in such cases the Psychiatrist is consulted.

Ÿ Only with an MRI scan a proper diagnosis as to whether the infec on 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 pa ent was admi ed in the ICU.
Findings and Discussion

Ÿ It is evident from the case sheet, the history of black out one month back is noted.

Ÿ Moreover, in the consulta on record on 25.11.98, it is men oned that the pa ent, when seated tended to fall to the bed.

Ÿ It is also noted that when he was made to stand and asked to walk he could walk without support.

Ÿ It is further men oned 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 suggested MRI scan to rule out the rare possibility of ADEM was advised.

Ÿ At 6:30 p.m. on the same day, it is men oned in the case sheet that at mes the deceased answered to ques ons 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 shou ng and violent nature.

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

Ÿ Evidently since 23.11.98 there was no administra on of diazepam. Admi edly the pa ent was treated by the specialist doctors in Psychiatry, Medicine and Neurology.

Ÿ It was persis ng 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 It is the case of the opposite par es that some sort of abnormal behaviour will be shown by the pa ent afflicted with ADEM.

Ÿ It has also been noted that although in the version filed by the opposite par es the case of head injury and black out was specifically men oned and the same was not denied in the examina on of PW2.

Ÿ It is only when specifically ques oned in the cross examina on that they have denied that the complainant had a head injury.

Ÿ In the circumstances it appears that PWs 1 and 2 are not speaking the truth.

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

Ÿ All possible tests i.e. CT scan, CSF 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 consulta on treated the pa ent.

Ÿ What was the illness as such could not be diagnosed finally. No medical literature has been produced to substan ate 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 shi ing the pa ent to the ICU, if the pa ent was violent.

Ÿ Further just an error in judgment or such a mistake in diagnosis cannot be considered as ac onable negligence on the part of the opposite par es.
Judgment

Ÿ In view of the circumstances presented, the State Commission declared that the complainants have failed to establish that it was on account of the carelessness and negligence on the part of opposite par es that the pa ent happened to kill himself.

Ÿ In the result the complaint was dismissed.

Take away points1,2

Ÿ Negligence in the context of the medical profession necessarily calls for a treatment with a difference.

Ÿ Medical prac oner is not liable for negligence, simply because things went wrong from mischance/misadventure through error of judgment

Ÿ In order to infer rashness or negligence on the part of a professional, in par cular a doctor, addi onal considera ons apply.

Ÿ A case of occupa onal negligence is different from one of professional negligence.

Ÿ A simple lack of care, an error of judgment or an accident, is not proof of negligence on the part of a medical professional.

Ÿ So long as a doctor follows a prac ce acceptable to the medical profession of that day, he cannot be held liable for negligence merely because a be er alterna ve course or method of treatment was also available or simply because a more skilled doctor would not have chosen to follow or resort to that prac ce or procedure which the accused followed.

Ÿ Simply because pa ent not favourably responded to treatment given by doctor, doctor cannot be held straightway liable for medical negligence by applying doctrine of res ipsa loquitur.
(Reference: 1. h ps://indiankanoon.org/doc/42396505/ 2. h ps://indiankanoon.org/doc/137673866/)

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