(1.) MR . Justice R.K. Patra, President -Being aggrieved by the order of the District Forum directing the Managing Director, SAIL, Rourkela Steel Plant, Rourkela and the Director, Medical & Health Services, Ispat General Hospital, (in short IGH) SAIL, Rourkela Steel Plant, Rourkela to pay to the complainant (Trinath Das Mohini) Rs. 3,00,000 as compensation, they have filed C.D. Appeal No. 72 of 1998. The complainant -Trinath Das Mohini has filed C.D. Appeal No. 73 of 1998 contending that the amount of compensation is inadequate. Both the appeals being analogous, they were heard together and are disposed of by this common order.
(2.) THE Steel Authority of India, Rourkela Steel Plant, Rourkela runs the IGH at Rourkela. The complaint was filed alleging that the complainant's son (Manas Ranjan Das Mohini) died due to the medical negligence of the attending doctors of the IGH. His case is that Manas (hereinafter referred to as the 'deceased') suffered from fever with a temperature of 1000 F on 13.9.1995. He was taken to Dr. Bishnu Priya Dei for treatment who prescribed certain medicines and advised for pathological examinations. The blood sample was examined for detection of Malaria Parasite, but report was negative. When his body temperature fluctuated from 1010 F to 1020 F till 16.9.1995, he was again taken to Dr. Bishnu Priya Dei who advised for further pathological test. On 19.9.1995, from the test report, it appeared to be a case of Malaria Parasite (positive). The complainant was advised by one Dr. Ashok Pal to take the deceased to IGH for better check -up. On the same date (19.9.1995), the deceased was admitted in the I.G.H. Rupees 500 was deposited as initial deposit. His blood sample was taken for examination. The treating doctor informed that blood report of the deceased revealed as Malaria Parasite (negative). On 20.9.1995, the complainant visited his son and the doctor after making general check -up informed him that after pathological report, he would be discharged. On the same date at 6.30 p.m. when he visited the I.G.H. he was told that the deceased was shifted to ICU. He could know that one nurse injected a saline and the temperature of the body of the deceased shot -up. The doctor on duty attended him at about 12.00 noon and prescribed injection which was not available in their store. The complainant purchased injection from outside and the doctor injected the deceased with it by removing the saline. After few minutes, the deceased cried with pain and at that time, no doctor was present. At about 2 p.m., the treating doctor reached and rushed to the ICU. When the complainant asked him as to why the deceased was shifted to ICU he was told that because the deceased became seriously ill. On 20.9.1995, he was declared dead. On these main allegations, the complaint was filed. In the written version filed on behalf of the IGH, it was stated that the deceased was suffering from Viral Encephalitis. For such disease, no definite medicine is yet available. The treatment prescribed for it generally symptomatic treatment. However, the deceased was provided with best possible treatment. On 19.9.1995 at about 3.30 p.m., the deceased was admitted in the medical ward with the complaint that since 13.9.1995 he was suffering from fever. He was attended by the physician on duty. For remission of fever, he was given medicine and pathological tests were recommended. Pathological test report did not reveal presence of Malaria Parasite in blood. Injection Cifran 200 mg. Intravenous was administered twice daily considering his suffering might be related to enteric fever. On 20.9.1995 in the afternoon, he developed high temperature with convulsion. He was immediately attended by treating physician. On examination, the condition of the deceased was found critical and, therefore, he was shifted to ICU. The detail diagnosis revealed that the deceased was suffering from Viral Encephalitis. He was given I.V. fluid injection dilantin 100 mg. 8 hourly to control convulsions. Mannitol injection and cifran were administered. All possible efforts were made for necessary treatmet in the ICU. Injection Dopamine 400 mg. in Dextrose was continued with Injection Efcorlin 200 mg. combating hypotension. But the deceased did not respond to the medicine and gradually went to coma. On 21.9.1995, he was monitored by the doctors but no progress was noticed in his health condition. On 22.9.1995 about 8.20 a.m. he died with hyperphxia brain stem injury due to Viral Encephalitis.
(3.) THE District Forum held that there was lapse, negligence in duty and deficiency in service on the part of the opposite parties in not giving treatment to the deceased and, accordingly, awarded compensation of Rs. 3,00,000.
In view of the nature of the case, we requested Dr. P.K. Das, Professor and Head of the Department of Medicine, S.C.B. Medical College and Hospital, Cuttack to examine the papers and render his opinion. All the relevant papers were sent to him. In his report dated 31.5.2007, he opined that treatment given to the deceased at various stages in the I.G.H. was "reasonable" and there was no wilful negligence at any point of time during course of his treatment by the attending doctors. Objection has been filed to the report of the expert. As the objection is not based on any contra expert opinion, we do not attach any importance to it. The expert (Dr. P.K. Das) is no way concerned in the case and his opinion being independent, we give due importance. The deceased was aged about 15 years. The expert says that provisional diagnosis of Enteric fever/malaria made by the Chief Medical Officer, I.G.H. was consistent with the investigation done outside prior to hospitalization in IGH. The deceased was examined by Dr. S. Mohanty, Medicine Specialist of the IGH on 19.9.1995. The expert says that Rourkela is an endemic area and the deceased was having intermittent fever. The treating doctor had done no wrong in stating presumptive therapy for malaria with chloroquine, which is practised as a thumb rule in management of fever in India as per the NMEP guideline. On the next day, two senior consultants Dr. S. Mohanty and Dr. D. Mohanty attended the deceased and they changed the treatment schedule to injectable Quinine (drug of choice for falciparum malaria at that time) and Cifran in order to cover Malaria and Enteric fever (the deceased had evidence of suspicion about Enteric fever and Malaria in the investigation report done earlier before his hospitalization). The expert says that from 13.9.1995 till his death, the deceased had variable presentation, investigation findings and downhill course baffled the treating physician at each stage. It was thought to be a common fever by first treating doctor (Dr. Bishnu Priya Dei). The other doctor (Dr. Ashok Pal) suspected to be problematic for which he referred the deceased to I.G.H.
Regarding controversy on the administration of Cifran, the expert says as follows:
"The cifran is a broad spectrum, relatively safe, world wide approved and widely used antimicrobial drug and is used for many infections including Enteric fever for which widal test is being done. The manufacture, nor also any test books recommend senstitively test and/or specific tests before the use of this drug. It is not absolutely contraindicated in children, though is usually suggested for avoidance due to effects on joints in animal models. However the dose recommended in children when to be used is in the range of 5 -10 mg/kg. per day in divided doses. The patients had an report of partially positive widal test (probably because of early test i.e., on 4th day) which has possibly tempted the treating physician for choosing this drug in this case for wide coverage including for Enteric fever."
The expert has found that the deceased was stable till 12.45 p.m. on 20.9.1995, after which his condition started deteriorating rapidly in terms of restlessness, convulsion and he finally lapsed to coma, requiring active treatments including ICU care. The expert says:
"The attending doctor has done nothing wrong by transferring the patient to ICU for cardio pulmonary resuscitation and ventilation therapy which had been undertaken till 22.9.1995 in order to save the patient as to even revive the patient with respiratory arrest. It would have been unethical or even negligent act on the part of the doctor had she not transferred the case to ICU for resuscitation where such facility is available.
After hospitalization when the febrile patient developed the features of brain affection (encephalopathy) physicians are bound to bring Encephalitis (inflammation of brain usually due to virus invasion for) into diagnosis after finding a normal cerebro spinal study excluding meningitis, negative Malaria and widal reports. However, they included coverage of these two later conditions (Malaria & Enteric fever) in the treatment schedule because of their commonness in the region and also in view of investigation reports done outside (submitted during admission). Although two doctors Dr. Dei and Dr. Pal had made it clear that they had not found evidence of encephalitis during the period of their treatment, the diagnosis of encephalitis provisionally cannot be ruled out beyond reasonable doubt after onset of restlessness, convulsion, cardio respiratory arrest, all of which can appear after a variable period of prodorm such as fever, myalgia and weakness as has occurred in this case.";